The Worth of a Pharmacist
Steph’s Note: This week, we’re doing something a little different. Maybe it’s because of my social media feed, maybe it’s a result of work, I don’t know. But what I do know is it seems we could all use a change of pace - positivity! (Image) I’m so tired of reading posts about pharmacists needing to “stay in their lane”, “just do what the doctor said”, and the list goes on. So we at tl;dr asked you to send us your good catches: big ones, small ones, student ones, veteran ones, ones from all walks of pharmacy life. Because maybe we need a moment to remember the good we all do, in all settings!
So enjoy this glimpse into a pharmacist’s worth. And if you have a (de-identified) story to share, please send it to steph@tldrpharmacy.com for inclusion in a future post!
The Purulent Wound
I received a cephalexin script for a purulent wound. I spoke with the provider regarding the concern for MRSA, but the provider stated they didn't feel it was that bad. The patient returned within 2 weeks and was put on sulfamethoxazole/trimethoprim (Bactrim) instead. ~Clarissa
The Precision Medicine Win
I review genetic panels that analyze genes that may impact an individual's medication experience. I have had several patients with really crappy panels. What I mean by this is they have poor or intermediate function of really important drug-metabolizing enzymes. We review medications to which they have had significant adverse drug events, and "It all makes sense."
Sometimes people cry.
They cry because they have been told it is in their head, or they need psychiatric care. (No joke, several patients I have reviewed panels for have been told that they are crazy.) I'm so grateful that I can do this because it isn't just about showing them they aren't crazy (although that is lovely!). It is about helping them find actions to overcome the barriers their genetics have set forth.
They have poor function of both SLCO1B1 and ABCG2? No problem. That is information you can provide to your doctor for prior authorization to get approved for a PCSK9i so there’s no messing around with muscle aches and pains in order to prevent an MI. Those genetic results get prior auths approved! They now have clinical evidence that they can't metabolize statins appropriately. BAM.
I get to make my patients feel better AND get them on preventative medications that are sometimes hard to get approved. Win. Win. ~Leticia
The Medication Reconciliation Mystery
We had a woman who moved from out of state and presented to our hospital with a CHF exacerbation. She stayed in our ICU for a little while. We stabilized her and sent her out on goal-directed medical therapy (GDMT), including a new sacubitril/valsartan (Entresto) prescription. That patient presented a few weeks later with the same clinical picture, and while I was reviewing admission orders, I called to double check that she had started her Entresto prescription.
The outpatient pharmacy reported that she had instead refilled an old lisinopril prescription and had not filled Entresto. I called the hospitalist, and we confirmed her last dose of lisinopril, waited for the washout period and restarted her Entresto, making sure she had the proper education and medication access the second time around. Moral of that story: medication reconciliation is important EACH admission. It’s not enough to trust a recent admission. ~Evan
The Risky Shift Change
We had a man who presented with severe pancreatitis and a PMH of HIV who was non-compliant on his ART regimen. The admitting hospitalist ordered a CD4 count and viral load, but the results were still pending during the hospitalist shift change. The new hospitalist was focused on the pancreatitis management, so after his rounding note was posted and didn't address a CD4 count of 140, I reached out to recommend Bactrim DS for opportunistic infection prophylaxis and to get him set up with ID at discharge to re-establish ART. Moral of that case: shift changes are risky in all departments, and communication between outgoing and oncoming providers can be misinterpreted. ~Also from Evan
The “I Looked into the Kinetics” Win
Dorothy Ann definitely grew up to be a pharmacist!
A few years ago while attending multidisciplinary rounds on a general medical unit, the attending mentioned a patient with Parkinson’s was quite discouraged. He had a significant delay between awakening and his ability to mobilize. If memory serves me correctly, he had a dose of both long-acting and short-acting levodopa/carbidopa quite early in the morning. To administer it to him any earlier would mean disrupting his sleep. Because I love a challenge (go pharmacy!), I looked into the kinetics. (Image) Lo and behold, I discovered that if you give levodopa/carbidopa with a carbonated beverage, it decreases the onset of action.
And again, if memory serves me correctly, it made a difference. ~Darlene
The Suspected DVT
We had a patient starting abiraterone and prednisone for prostate cancer. At our two week check in after initiation, we were reviewing if he had any new side effects or anything to report. He mentioned he was tolerating the treatment well, but his wife jumped in and said one of his legs was swollen. After a discussion about onset of symptoms and several follow up questions, I asked him to go to the ED for evaluation, and we discussed the risk of DVT. It was a DVT. Patient was very grateful that it was caught early. ~Melanie
The Persistent Mucositis
We had a patient on pembrolizumab and capecitabine for breast cancer reporting mouth pain. We discussed holding capecitabine, and she started standard mucositis management. But after a week, she still described the sensation of "razor blades" in her mouth. We discussed the possibility of immunotherapy-mediated mucositis and started her on dexamethasone mouth rinse. Mucositis improved, and she was able to resume capecitabine and continue treatment. Of note, we have several patients with immunotherapy-mediated mucositis and are starting on a case series paper. ~Also from Melanie
The Sneaky Supplement
I was taking care of an 18 year old patient with no significant PMH and no prior psychiatric history, who was sectioned at the local gym after developing unusual/erratic behavior and psychotic symptoms. When I was reviewing his labs with the team, a few things just seemed...weird for an otherwise healthy adolescent: BUN 28, creatinine 1.34, AST 78, ALT 47, and elevated B12 and folate.
I didn't see anything on his medication list that really explained what we were seeing, so I asked the team if anyone had asked him about supplements (they hadn't). The team brought it up with him during their next interview, and he reported taking creatine 5 g daily, ashwagandha, zinc, magnesium, calcium, and fish oil. He was buying all of them online.
We ended up talking with him about the supplements and recommended that he stop the unnecessary ones, or at least use products with some level of third-party verification (like USP) if he wanted to continue taking them. We're also following up on his labs.
It also made me wonder whether there could be other products he wasn't considering “supplements”... things like pre-workouts, energy/focus products, or nootropics that we hadn't specifically asked about. I don't know if he was taking anything like that or if any of these products contributed to his presentation, but it was a good reminder for me when I'm asking about substance use (especially with younger patients!), I probably need to ask more specifically about the whole supplement/performance product world too.
I was actually pretty proud of this intervention. It was really just noticing that something didn't add up and thinking beyond the prescription medication list. Especially with a young patient who is otherwise healthy, it's easy to overlook supplements unless you specifically ask about them. ~Lara
The Devil’s in the Dosing Details
Recently during ICU rounds, I noticed that we had a patient on DVT prophylaxis with enoxaparin 40mg subcutaneous daily. The cardiology note clearly said, “Patient on VTE dose Lovenox and will discharge on a DOAC.” I alerted the ICU team, who was unaware. The order was changed. ~Sara
The Hot Shower Clue
I diagnosed a patient with cannabinoid hyperemesis syndrome. Everyone else on the care team was struggling to figure out why our patient continued to have severe vomiting even after all the tests came back negative. Then one of the nurses mentioned in a very off-handed manner that the patient only felt better in the shower, and I was like BINGO!
I asked the provider if the patient had a history of cannabis use/abuse, and she absolutely did. I suggested Aspercreme to the abdomen, and it worked like a charm, which led to the provider having a hard discussion with our patient about their life choices. It felt really great to both find the cause and provide a recommendation to solve the problem. ~Abby
Why Route of Administration Matters
Wrong route? Whoops…
This is a fun one. As a student on inpatient rounds, the team could not figure out why the pupils were dilated in a patient who was in a coma. I realized that they were administering the atropine eye drops into the eyes, when they were actually prescribed to be placed in the mouth to minimize secretions. ~Ashley (Image)
The Dapsone Detective
We had a patient sent from an outpatient psychiatric facility for hypoxia. The patient was there to get a voluntary admission, and during their intake, they checked an spO2 and it was 72% on room air. They called EMS and sent them to us. On arrival, the patient was not struggling to breathe but was hypoxic, even on oxygen. The PA I was working with got some labs, including an ABG.
The lab called in a panic that the patient had an elevated methemoglobin level. I was asked to look at her medication list. The PA questioned the patient about illicit drug use - poppers, nitrous, etc. The patient denied everything except THC. The current medication list did not contain any meds known to cause methemoglobinemia.
Knowing what meds are usually implicated, I started digging in the chart. Apparently, the patient was on dapsone for acne earlier in the year but stopped taking it, so it was removed from the med list. After questioning the patient, they admitted they took 10-12 of the 100 mg dapsone tablets with intent to harm themselves. They stated the psychiatric facility was aware of this, but no one communicated that to the ED. An ICU admission and multiple doses of methylene blue later, the patient was sent to the psychiatric facility for their treatment. My APPE student helped the ED RN hang the first dose of methylene blue, and both walked out with blue fingernails. ~Jennifer
The Fluid Calculations Win
When I used to work on the oncology floor, I had a patient with what the chart said was refractory hypercalcemia due to malignancy. The MD notes said they were giving calcitonin and IV fluids, and they were considering a bisphosphonate next. The patient had been on the floor for 3 days at this point.
On chart review, the patient was receiving lactated ringers (LR), not normal saline, for their IV fluid. Given there is calcium in LR, I did the math, and the patient had gotten 60 mEq of calcium between boluses and high rate of infusion for a few days. I alerted the MD to change the fluids and had to get out a bag of LR to prove it really did have calcium in it. I finally got the patient changed to NS, and the calcium dropped to normal range over next two lab checks. ~Also from Jennifer
The Daptomycin Discovery
I recently had a patient come in from a skilled nursing facility (SNF) for a clotted PICC line. He was getting daptomycin for MSSA bacteremia/endocarditis as the facility could only do once daily IV administration. He had been our patient before being sent to a larger hospital in our system for removal of his pacemaker leads, and then he was discharged from there to a local SNF.
While we were discussing how to declot his PICC line (hurray CathFlo!), the PA seeing the patient told me how tired he was and that he was having myalgias. I recommended checking a CPK and then found out his statin was not stopped by the discharging facility when starting his daptomycin. Needless to say, his CPK was almost 4000. The local outpatient ID doctor never followed up on weekly labs requested by the outside hospital ID on their discharge. The patient was admitted to manage the rhabdomyolysis and changed to oral linezolid so we could pull the PICC. ~Also from Jennifer (doing work!)
The Unlabeled Radioactive Material
As a nuclear pharmacist, a pharmacy tech sent out an Illuccix without the label attached to the lead shielded container the 10 CC syringe was in. I called the driver back to the pharmacy to attach the label. ~Alex
The Insulin Close Call
Recently working at a long term care pharmacy, I caught a U-200 insulin degludec that should’ve been a U-100 insulin. ~Also from Alex
The Sotalol Paradox
I had a tag team intervention with our cardiology pharmacist (a few times actually). Sotalol IV therapy initiation is interesting because the loading dose for worse renal function is actually higher than for good renal function. Of course, the target oral dose would determine what loading dose you need.
A handful of times, I have had providers order a higher loading dose than what was indicated based on their good renal function. For example, the provider ordered 125 mg IV when they should have ordered 90 mg IV for CrCl >90ml/min. This has resulted in providing education to these physicians about sotalol dosing specifics. ~Candace
The Apixaban Dose Reduction Triad
I was able to make a good catch at a retail pharmacy getting a little old 83 year old lady on reduced-dose apixaban. As I was checking her script, I remembered a little tidbit from pharmacy school about the 3 reduced dose criteria for atrial fibrillation: age > 80, weight < 60kg, SCr > 1.5mg/dL. She met two of the criteria, so I talked to her at pickup. She'd never been told that before. I called the doctor, and they sent over a reduced dose. Wahoo! ~Tyler
The Amoxicillin Conversion VIP
I work retail, and a few months ago, I got this panicked call from a dentist's office. One of their patients needed prophylaxis for endocarditis and couldn't swallow tablets. The office only had one order set and had never prescribed anything other than amoxicillin 500 mg x4. So this was out of their depth, and they wanted some clinical input. I ended up talking the medical assistant through the math to get the same dose with liquid amoxicillin, and you could hear the entire office in the background sighing in relief.
It's funny because dose calculations was something I learned in year 1 of grad school. It's foundational but nothing to write home about. But for that office, this was mind-blowing, and it solved a really big problem for them. It was that moment where you walk away feeling like you genuinely left something better than you found it. Those are the standout moments for me. ~Hannah
The Chart Review Eagle Eye
I arrived at a full code on a young 20-something year-old adult. A full code on a 20+ year old is unusual. I noticed on their PRN meds that insulin had been given about 30 minutes earlier. I recommended IV push dextrose, and the patient woke up immediately. That could have ended badly. ~Dale
When Pharmacy Knowledge Becomes Personal
My grandma has stage 4 cancer. During one of my APPE rotations, she was on apixaban, and she had an upcoming surgery. My mom and aunt are her primary caretakers. My mom told me she received a patient education pamphlet with a generic "Stop your anticoagulant 5 days before your surgery." I told her that is too long, and it should only be about 2 days. My aunt told the oncologist, and the oncologist agreed with me. He said 2 days should be sufficient. If I didn't say anything, she would have stopped taking her apixaban 5 days before her surgery.
It was a cool way to see my pharmacy knowledge start to merge with real life scenarios even from just starting my APPEs. ~Libby
And there you have it - pharmacists doing STRONG WORK everywhere! From students to veterans, retail to inpatient, YOU are impacting people’s lives. Don’t ever forget that.
Want to read more? Send me your interventions at steph@tldrpharmacy.com!