Goodbye VAC

Yesterday was my last day at the VAC. My preceptor left for Florida yesterday, so all I really had to do was clear post and then I could leave. On Thursday, the staff had a party for me and the other student from my pharmacy school. They bought a cake and had our names put on there along with "We'll Miss You!" They also bought us gifts. I got a nice candle and Boyd's Bear figurine. Very cute! Yesterday was tough...I had to say goodbye to everyone. I don't like saying goodbyes. It seems like with these rotations, as soon as I know my way around and really feel like part of the pharmacy team, it's time to leave. I was told that I am a serious candidate for their residency program...and the staff told me that they were pulling for me the whole way. I've been invited back for a Thanksgiving lunch and they would not take "no" for an answer. :)

Last night I went to pharmacy school Halloween party. It was terrible (and I think that may be an understatement). I was home watching TV at like 11:30... Bad ending to a pretty good day. :-/

Finding Faith

I watched a man die today. I have never seen death occur. I have seen those on the brink of death and I have seen those in which death has occurred, but I have never seen death in action. I went to ICU rounds this morning expecting to discuss the new admit intracranial hemorrhage patient...and eneded up finding God. While we were waiting for the ICU attending to make some phone calls for a possible transfer for the intracranial bleed patient, a nurse approached me and Ms. Resident. She asked us if we had ever seen anyone actively dieing. I replied that I had not, and she asked me to come with her. She led me into a 51yo man's room. He was lying in bed with his eyes open, but glazed over. Every 5 seconds he would inflate his lungs to their tidal volume with an irratic breath. I had seen this breathing before - my Nan had agonal breathing periods before she passed away. I had never seen agonal breathing to this degree. His respiratory rate was 18, his BP 78/52, HR 78, and O2 sat a horrible 68%. The nurse immediately left the room to call his next of kin - a sister working in DC. She could not make it back to the VAC. ICU rounds began and I positioned myself so that I could monitor his EKG out of the corner of my eye. About an hour into rounds, he started developing VPBs - irregular ventricular beats - a sign the heart was weakening. The family for the intracranial bleed patient arrived - so we let them have some time with that patient. Ms. Resident and I went back to the dying man's room. The nurses had turned the radio on and placed it by his head. They pulled his blinds open so he could see the sky. A little after 10, his heart rate started to decline rapidly, as well as his blood pressure. His BP was 42/22 and his heart rate 44. The nurse put her gloves on and went to stand by his side. She kept touching his shoulder, as if to let him know it was going to be ok. He stopped breathing and his heart rate continued to slow, until finally a flat line was seen on the monitor. I think it was this moment that I found faith...or rather it found me. The finality of his last breath scared me...and then, I felt calmer. I took comfort in knowing that he was no longer in pain and that perhaps he was really in a better place. The ICU attending walked up to the patient, listened for heart sounds and palpated for a pulse. He pronounced him at 10:05 and softly closed his eyes for him. For the first time the whole morning, his body looked at peace. I blinked back tears and walked out of the room. They drew the blinds and closed his door. I was emotionally drained. I found myself crying on the way home - reflecting on what I observed. I guess without faith, death really is final. I'm glad I found my faith before I lost it for good...

VAC Hodge Podge for $200

The VAC was full of laughs today, as well as an indepth conversation with a medical doctor concerning patient's rights and health care providers' personal feelings. First some humor!

NH Hallway @ 0915:
[Little old man wheeling himself down the hallway]
Little old man - *squirt*
Ahsirt - [thinking to self "Dear God he's pooped himself."]
[Ahsirt running back up hall to little old man]
Ahsirt - "Sir can I help you?"
Little old man - "No missy, I'm fine, I'm just vomiting."
Ahsirt - "..."
Ahsirt - "I'll get you some help. Wait right here."
[Ahsirt turns to get some help and little old man puts wheel chair in high gear leaving rubber behind.]
*Ok...fine and vomiting just don't go together! As I walked down the hall, I realized the little old man had vomited every 4 feet...housekeeping!*

Med Rounds @ 1300
After discussing the four patients selected for med rounds today, TK asked the medical team if there were any other patients or issues they wanted to discuss. Doc H asked, "When's the last time someone around here got Marinol?" TK, Ms. Resident, and I looked at each other and smiled. We had been waiting for an opportunity to share our feelings on the injustice JC had done by trying to deny the request for the drug. Our discussion lasted for about 15 minutes and then Doc H made an allusion that I immediately caught. He said, "If you had an alcoholic uncle that use to beat you, that doesn't mean you can refuse to treat an alcoholic. In the health care field, you put your personal beliefs aside for the betterment of the patient." Point well taken. He was alluding to the fact that JC refused the med solely on the basis that the patient was an AIDS patient. That is morally, and more importantly, ethically wrong. I couldn't agree Dr. H more on the topic of personal beliefs...and I told him so myself. I left the room feeling quite refreshed - finally someone else in the health care field with the same beliefs.

And finally...one more humorous story

Escape to the Titty Bar!
One day about two years ago, Mr. Hornypants disappeared from the nursing home. The nurses and staff searched everywhere for him. He was no where to be found. As they were getting ready to call the police, a Dom member informed the staff he saw Mr. Hornypants get on the local bus and leave. When the driver of the bus was tracked down, it was discovered that he had dropped the patient off at a local "establishment." When a team of health care providers arrived at the local titty bar they found Mr. Hornypants sitting outside the door waiting for the place to open...the kicker - he had a sombrero on his head so he would not be recognized!! HA!

The Sins of Mr. Righteousness

I had never experienced AIDS until this rotation. I became acquainted with an advanced stage AIDS patient during my second week at the VAC. At that point he was receiving TPN and was moderately weak. Since then, his state has only deteriorated exponentially. He has been taken off TPN and has developed extreme nausea and vomitting. Every time he eats or takes medications, he vomits about 20 minutes afterwards. We have tried every possible anti-emetic in this patient - prochlorperazine, ondansetron, metoclopramide, etc. A specialist physician from another facility who has treated this patient before recommended dronabinol (Marinol). Marinol...sounds a lot like marijuana...and it should because dronabinol is a derivative of THC, the active ingredient in marijuana. Dronabinol can be used to increase appetite in AIDS patients and can also be used to decrease the nausea and vomiting associated with AIDS medications. Of course, dronabinol is a non-formulary product. In order for the patient to receive the medication, pharmacy has to approve its use...or the chief of medicine has to approve it. While the approval is usually given to the pharmacist in charge of the department it will be used in, this non-formulary request was given to JC. At lunch, TK, Ms. Resident, and I approached JC in regards to the request. The three of us had spent a portion of the morning researching the product and its appropriateness. We were recommending its use. When approached, JC informed everyone in the inpatient pharmacy that, and I quote, "No one would be receiving THC while he was a pharmacist at the VAC." He then went on to say, "What do they think they're going to do...make him so high he can't remember he's sick?" Ms. Resident, TK, and I were very upset by these comments. Low and behold, JC denied the request and recommended the use of ondansetron (which the patient failed miserably on). I was not disheartened, because I had a feeling the chief of medicine would take care of this problem...and she did. She also slammed pharmacy for its poor chart review and blinded ignorance. Ms. Resident and I wanted to put an addendum on her note saying, "We concur with medicine." This follows right in line with pharmacists pushing their personal beliefs on patients. JC is a staunch Republican with strong views. He let his personal views on marijuana and possibly even AIDS dictate his decision. Clinical information was not even evaluated by JC. It is insanely ridiculous that this patient would be denied a medication because it may cause euphoria. For God's sake, morphine can cause euphoria! I suppose JC would feel that patients in unretractable pain should be denied morphine due to the chance for euphoria. After receiving medicine's reply, I made a trip to the patient's room to see him. He was lying in bed with his eyes rolled back in his head and trembling in pain. I couldn't help but think to myself that if he did receive a little bit of euphoria from the dronabinol, it wouldn't be such a bad thing. I doubt he will survive to receive a dose anyway. The medication won't arrive until Wednesday, and I'll be very surprised if he makes it to then.

Egghead Gets Served

At the VAC, there are students from three different pharmacy schools. Egghead goes to ABC-U...and every day I'm with him, I become more and more elated that I did NOT choose that university. I guess in all honesty, I should not judge ABC-U by just one student. A new student starts Monday, so I will truly evaluate the school at that time. That aside, Egghead has become more and more annoying. Today was his presentation - which drug on (no pun intended...) for 45 minutes. Even the Director of Pharmacy Services was drooling into his lunch. After lunch, there was yet another IDT meeting - this time involving Unit A. I was a bit apprehensive about the meeting given yesterday's outcomes. The meeting, however, was quite entertaining. Egghead and Ms. Resident (the pharmacy resident) almost got in a fight at the table. Egghead told Ms. Resident that she was not making adequate recommendations and that he should have the patients' charts. Ms. Resident was not happy. (Side note - it is quite evident that Egghead has never worked with the elderly or with patients receiving palliative care. There's a reason it's called "palliative" care...and it's not because they poke and prod you causing you more misery!) Egghead was outraged that these patients were not receiving regular blood sugar checks, Chem-7 panels, and ABGs. What an ass. If I had cancer and was dieing, I'd tell the nurse where to stick the needle. Here's the moment of the day - a snipet of conversation from the IDT meeting:

Egghead - "Well now I'm going to say something that pisses everyone off."
Nurse Manager - "Can't piss me off - I don't prescribe the stuff, I just give it."
Egghead - {arrogant chuckle} "Well, bisacodyl is contraindicated in the elderly unless the patient is receiving long-term opioid therapy. If you would read the Beers Criteria, you would know this."
Nurse Manager - "Patient LMNOP requires a bowel regimen."
Egghead - "Well, I'm recommending D/Cing the bisacodyl."
Nurse Manager - "Ok buddy. When patient LMNOP becomes impacted, I will allow you honors of fixing that problem. Make sure you bring big gloves."
IDT team - {roaring laughter}
Egghead - "...."

HAHAHAHA! Egghead the ass got it right where he deserved it - that is if he understood what "impaction" is...HA!

Dissention in the Ranks

Today marked my first day in the long-term care department at the VAC. I went into today with high expectations - a sure sign that shit was going to head down hill fast. Allow me to say first that TK is a very friendly person and has a good repoire with the patients and the staff (after the IDT meeting it became more clear to my why this is...but that's going to be elaborated upon here shortly). First thing we did this morning was deliver IVs to the med rooms in Unit A and Unit B. When we placed the Primaxin IV in the Unit A refrigerator, I noticed a case of Schlitz sitting on the shelf. I thought it would odd for a detox patient to be in the long-term care unit, so I asked why the beer was there. TK told me that since the goal of the long-term care unit was pallative care, the guys (and gals) were allowed a beer if they wanted one. I think that's just plain awesome. I've never been to a nursing home that served beer before! The rest of the day paled in comparison to the beer discovery. This feeling was culminated at the IDT meeting. IDT stands for Interdisciplinary Team - which is a crock. It should be called the Nursing and Dietician team, because the physicians' and the pharmacists' input counted for very little. The dietician was extremely rude and very unprofessional. She made off-collar comments about patients and when medication suggestions were made, she actually laughed at the pharmacy staff. I came this close to saying - "You are a dietician. You deal with food and nutrition. I don't tell you what to feed your patients - don't tell me what medications are best for the patients!!!" I have worked with wonderful dieticians before...this woman was a bitch. Then there was the nurse manager that makes Freddie Kruger appear to have a good bedside manner. We were discussing a patient with a Stage II pressure ulcer, and I recommended an Akton pad for accelerated healing. You thought I would've suggested removing her right arm! She informed me that those pads are not for pressure sores and my idea would never work. I wanted to inform her that obviously her nursing techniques do not work because a patient should NEVER have a stage II pressure ulcer. Skin break down occurs because of neglect. Instead, I bit my tongue and replied that my sister is vice president of the company and would be more than willing to re-educate them on this misconception. She shut up and noted to NOT take my recommendation. The IDT meeting drug on for 2 and 1/2 hours...the resident and I spent the last 30 minutes playing "doodle duel." We competed for the most aw-inspiring doodle. The activities director awarded co-first places. I finally trudged out of the VAC at 4:45 - 15 minutes past my normal quitting time. I say "boooooo" to long-term care!!!

To Be a Fly on the Wall...

Here's are some snippets from conversations that I was privy to at the VAC on Friday...

Old Man - "I'm 84."
The Scot - "Well, I wouldn't tell anyone that. You look like you're 50. You must be in great health."
Old Man - "Actually, I screwed up my lungs and heart by smoking, but my penis works great. I take care of the ladies."
The Scot - "You are a crude man."


LiarLiar - "I fell out of a chopper in 'Nam and shattered my spine."
The Scot - "What did you do, trip over your gun?"
LiarLiar - "No you sonofabitch, my parachute didn't inflate."
Irish Lady - "Did you hurt your arms?"
LiarLiar - "Lady, how the hell would I have hurt my arms?"
Irish Lady - "Well, it is just instinctual to put your arms out when you are falling."
LiarLiar - "Lady, my arms were full! I had a M-14 in one arm and my parachute in the other."
The Scot - "Well, perhaps that's why your parachute didn't inflate?"


The Scot - "Did you know the most deadly snake in the world is a brown cobra? Death ensues a mere 3 seconds after his bite."
RxAhsirt - "Really?"
LiarLiar - "You don't know your ass from a hole in the ground - the deadliest snake in the work is the Vietnam Viper."
The Scot - "I do not know of a snake by that name."
LiarLiar - "Well obviously you weren't in the jungle. It's more commonly known as the 1 and 1/2 step viper."
The Scot - "I think you're confusing your geography. The 2 step viper is indigenous to South America."
LiarLiar - "You Kennedys are all the same - think you know it all."
The Scot - "Again, your geography fails you man. The Kennedys were Irish, I am Scottish."

Mumbles the Pharmacist

Today was a disaster. The only saving grace was that CZ prepared me for this yesterday. Since he works this weekend, CZ was scheduled off today. CS, the IV technician, decided to take the day off as well. She decided to go to Baltimore to see a ScriptPro machine in operation (how dreadfully exciting) because she knew Mumbles was going to be the IV pharmacist today. Mumbles is probably less fun than the ScriptPro machine (and I only say probably because I have never seen a ScriptPro in action). I refer to this pharmacist as Mumbles because he does not open his mouth to talk - he just mumbles inaudibly what he wants to say. I have been making TPN in the hood since Monday - which I realize does not make me an expert. However, I would say that my aseptic technique is superb. This is mainly due to my OCD...but also due to my experience in the classroom, RW, and the past 3 freaking days at the VAC. Mumbles told me to hold the vials directly up and down when withdrawing liquid. I imagine Ms. Peacock would've had a heart attack at this command. (Mrs. Peacock was my sterile lab professor). In a vertical flow hood, the critical area is where the needle hub meets the vial. This area should be exposed to the direct air flow. When the vial is used vertically, the critical area is not exposed. At this point my OCD was in full swing - because not only was the needle hub "compromised", but I was also breaking my needle technique. I felt like a kindergardner in the hood. Mumbles kept mumbling orders in my ear, which is extremely annoying because #1 - I was in the hood trying to concentrate on the needle and #2 - he mumbles and I couldn't hear him over the roar of the hood. Finally, totally fed up, I put the needle down and turned around and said, "Well CZ watched me do this for 3 days and this is how he told me to do it and this is how I am going to do it." This totally pissed Mumbles off. He made some smart ass comment that sounded like, "Oh CZ...blah blah...TPN." As I recapped my needle so I could use a new needle to draw up the next solution, Mumbles screamed at me. I almost rammed the needle in my finger...at this point, I was a little on edge. He reemed me out for no less than 3 minutes about recapping needles. Ok - for the past 3 freaking days, I have been recapping needles. I was actually instructed TO recap needles. I wanted to say, "Well Mumbles, just because you can't f@&king see, doesn't mean I can't." Instead I just glared at him and threw the needle in the sharps container. Then at 11:55AM, we got a STAT order for 1 bag of Nafcillin along with 6 additional bags. Mumbles informed me that I was to stay in the IV room until I finished the order and then I could go to lunch and that he was going to lunch now. GRRRRRRR!!!! I had to find Eeyore (another affectionate name for an odd pharmacist who's paranoia probably classifies him for a room on the psych floor) to check to my bag and math. I hung out in the IV room until Mumbles returned from lunch and then informed him that I was going to lunch. He mumbled, "Well I assumed you would go when you finished this one bag." I said, "Well, I didn't, so I'm going now. See you in 30 minutes." After lunch Flo-Jo brought me some pens from a drug rep. I was in the hood, so she put them on the bench. Believe it or not, Mumbles stole them. Flo-Jo watched the theft and then came back in the room and stuck 2 pens in my pocket. She was pist. I was pist. I spent the rest of the afternoon wandering around the inpatient pharmacy, avoiding Mumbles at ALL costs. Thanks a lot CZ!!!!

Working in Da Hood

This is my week to be in the IV room. It turns out that this is probably the best week I could be in the IV room because CZ is the pharmacist. CZ is pretty cool. He pretty much lets me do whatever I want in the IV room, and he's quite a hoot to work with as well. (Could this be due to his friendship with ROMA?) Yesterday morning I mainly observed the workflow in the IV room. CS, the IV tech, is pretty cool too. She sensed my boredness with observation and let me work in the hood with her on her second set of IVs. The VAC has 3 patients on TPN (total parenteral nutrition), which is apparently an oddity. CZ told me that it may go 6 months and they won't have a TPN patient...now they have three. After observing one TPN being mixed (oh yea, the VAC doesn't have a machine, so everything is mixed by hand), CZ allowed me to pull up the quantities for the second TPN and inject them in the bag. Today - I had to perform the calculations and correctly fill the order. The TPN we made today was for an advanced-stage AIDS patient who has been NPO for almost a month. I made 2 bags for him, one for 0001 and one for 1100 (military time). The 0001 bag contained potassium chloride, sodium chloride, magnesium sulfate, calcium gluconate, regular insulin, amino acids 10%, dextrose 40%, and famotidine. The 1100 bag contained the same plus multivitamins and trace elements. The multivitamins are a bitch - the vial is double stoppered so you have to depress the top stopper to push the second stopper out of the vial. Then you have to be careful not to get a positive pressure in the vial because it will spray yellow, stinky liquid all over you. I sprayed just a little onto the hood and made the whole hood smell. As with my rotation as RW, I feel at home in the hood. I've already decided to spend one of my extra weeks at the VAC back in the IV room in the hood. I never thought I looked much the part of a hood rat...but it fits me well. :-p