Monthly Archives: June 2011

Triggers

June 27, 2011 – 12:48 pm

 

Our pharmacy is medium busy. During the day we run it with just a pharmacist and a technician. My technician types the labels and fills the bottles, and I, the pharmacist, verify the prescriptions, counsel the patients, and then charge them for our services at the cash register. The two of us make a good team, because I stand out there with the customers, solving the pick up problems, which leaves my technician undisturbed to solve the prescription processing problems. Our place is one of the big chains, but at one time it was a privately owned drug store. I guess you could say that the prescription department is somewhat shabby and old, and on the small side. Other than a video camera, it has zero security.  I never know who is going to walk through the door. Standing at the register I see plenty of good and some bad.

The kid in the halloween costume was a good memory.  During the middle of a hot summer,  a little boy dressed as The Green Lantern darted up to my cash register. It was a sight that put me into one of my better moods. This kid was no more than nine or ten, and was all skinny energy. He had the green legs and green arms, and eyes like bright sparks shone behind his hero’s mask. He pointed  his lantern ring at my head and shouted, “boom!”.

His parents followed a few seconds later.  The mom was holding prescriptions, the dad was holding his jaw.  They had dentist prescriptions. Those were easy work. Dentists usually write for two types of medications; a morphine-family  drug for the ache and a penicillin-family drug for the bugs.

-”Will it be fast? He’s in a lot of pain.”, asked the mom.

-”Daddy, is the man going to make you feel better?”, asked the super hero to his father.

I looked at the first prescription. It was for a  ”morphine-family” drug called Percocet. This is a stronger narcotic, so the pain was probably bad. We would fill it right away. This is a part of my job that I really liked.  It’s an example of the immediate difference that a pharmacy can make for a patient. Suffering and worry will usually start to melt as soon as you hand a patient their bag of pain pills. Even before they swallow a single tablet.

This triggers a memory of my own Percocet prescription, that was once written for me by an oral surgeon, after taking a wisdom tooth out of my head.  It was a stubborn tooth, so he advised me to fill the prescription right away.  Well the surgeon was right.  Before the pharmacist completed the filling of my prescription, a bullet of pain fired from my gum and lodged in my lower jaw. As soon as I could, I gobbled down a tablet and within thirty minutes that wild fire was reduced to a few glowing embers. The first day after oral surgery the Percocets were my miracle life jackets, and I clung to them every four to six hours.  After that,  I was out of deep water and I saved the last two tablets.  Like a boy scout, I took them with me when I lived away from home, attending pharmacy school.

And sure enough, one night I was awoken by another aching tooth.  To be honest this discomfort was only a fraction of that first one, but there is another component to all pain. It is anxiety. I was awake, alone, and feeling the first hints of an ache, which may, or may not, have grown into an agony. This was nerve wracking anticipation. So I had the two tablets in my bottom drawer. What the hell, I took a Percocet, even though I really didn’t need one.

Within minutes, I started to feel a warm sensation that began in both of my legs, and with it came a feeling of super human relief. Wow. It was like being in the middle of a rush of perfect peace, and just prior to falling asleep, my entire body felt like a prop in a porno movie. It was my first and only time that I abused a narcotic. I had been an accidental junkie. Since the pain wasn’t severe enough my brain had been focused on a Dopamine explosion that was caused by the Percocet.

Scientists will tell you that all addictive drugs involve an elevation of the neurotransmitter, Dopamine. It is the chemical that, under normal circumstances, rewards the organism for good behavior.  But man found drugs. And narcotics, which are very effective for taking away pain, artificially elevate Dopamine to an all time high. It was responsible for that rush that I had felt.  Luckily, my brain isn’t wired to become easily addicted.  The next day I realized that  the pain pill felt abnormally amazing, and I never touched the Percocet again.

It is not the same for the poor narcotic addict. This individual will always remember the first time they felt the rush. That flood of Dopamine fires from the base of the brain, then reaches into the frontal cortex, to wreak havoc with behavior and decision making. The addicted person can spend a good portion of their lives chasing that feeling. Their mind is consumed by a pursuit of that high.

This triggers a lot of bad pharmacy memories of me fighting battles with drug seekers. The board of pharmacy did not dress me for battle. They didn’t hand out a Green Lantern ring with my pharmacy license. Addicted individuals will try anything, tell any lie, and ruin any life, in order to stay high. Their actions can range from mildly amusing to breath-stopping scary.  One night I got fed up and called one of the doctors. While my rather large patient sat in the waiting area, I told the doctor that this guy had been getting multiple narcotics from prescriptions written at  Emergency Rooms all over town.  His doctor instructed me not to fill the prescription. He said to mail it back to him. After I hung up the phone, I was left with the task of telling this two hundred pounds of muscle he would not be getting his oxycodone; and I was keeping the prescription.

I am not complaining about people in real pain. I interned at a pharmacy in New York City during the late eighties.  AIDS was out of control. The pharmacy was located a block from a VA Hospital and NYU Medical Center.  I was there when hospice care first exploded in the city. Hospices with names like Cabrini and Beth Israel. My pharmacists bent all kinds of laws to keep the patients out of pain. Back then you could only dispense these powerful medications with a written “triplicate” prescription.  My pharmacists were taking thirty day supplies from hospice nurses over the phone, and worrying about getting the written prescriptions later. If they didn’t do this, I’m sure the health care system in New York City would have been overwhelmed.

The issue I am talking about is an epidemic of out of control abusers that are sucking the life out of my job.  It was never like this twenty years ago.  I left retail for a time, and when I came back, I discovered all these prescriptions for oxycodone 15mg and oxycodone 30mg. Whatever happened to good old Percocet?  This oxycodone 30mg is rarely a good idea for my pharmacy. We hardly ever carry it.  The one time I ordered a bottle for a patient, we got a call from Medicaid. They suspected that the patient wasn’t legitimate. And for weeks after that, my pharmacy was getting shady calls from all over the state. People somehow found out we stocked oxycodone 30mg and were determined to get some.  To use up the stock bottle I filled a few, and, honestly, for every single one I filled, it felt like I was part of a drug deal.

This triggers all the old arguments I’ve heard over the years about the war on drugs. I really think its time to fight it in a different way. One pharmacist and one technician aren’t trained to fight in a war. Really. Currently, its up to the two of us to figure out which patients are the phonies. After that determination, we have to decide if we have enough strength to engage in another battle.

I think I’m ready to say I’m done with it. Let them be addicts and get their fixes at some kind of state sanctioned pharmacy equipped to deal with a drug war and all the dangers that it entails. Narcotic abuse hijacks my energy away from helping my pain patients. And the dangers that it comes with are very real.  I’d rather be removed from the whole damn transaction, than be removed from the planet.

I imagine there would be four people in  New York  who might agree with me. If they could still speak.  Because this past Wednesday, someone named David Laffer was arrested for allegedly pulling a trigger  on four people and killing them at a pharmacy in Long Island. He then stole the drug store’s entire supply of hydrocodone, so he could feed someone’s drug habit. On June 19th, pharmacist Raymond Ferguson, 45,  clerk Jennifer Mejia, 17,and customers Jamie Taccetta, 33, and Byron Sheffield, 71, were all casualties in the war on drugs.

I wonder if the pharmacist was on the phone with an insurance company, or entering a prescription, before the robbery went down. He and his wife would have celebrated their 10th wedding anniversary this year. His partner that day was the 17-year-old store clerk. Maybe she was standing at her post near the cash register when it happened. She would have graduated from high school last week. I wonder if her family ever had a chance to take a picture of her  wearing her graduation gown. It might have been one last memory that they could have slid into a photo album. On a page somewhere past the older ones of a little girl wearing halloween costumes. Then her family would close the book and re-shelve it.

Which reminded me again of the family that came to my pharmacy. Me and the tech filled the dental prescriptions very promptly. The mom thanked me when I handed her the bag of pain pills. The dad’s face showed a little spark of relief. Their little boy  shouted boom, and he pointed his ring at someone as they exited the front door.  I was glad they picked my drug store. They could have walked into any of the pharmacies in our town.  Me and my tech couldn’t wait to go to our homes that day, so we could share dinners with our families. And tell them all about the Green Lantern that visited our drug store.

 

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The Blue Water Scandal and other Drug Legends.

June 20, 2011 – 6:09 am

This was retail pharmacy in the 1970s. Before there were drug chains, and managed care, and 17 different brands of the same oral contraceptive. Before there was HIPAA. And before the owner of the business became some faceless board of directors, hundreds of miles away from the pharmacy counter. I don’t offer much in the way of facts. I offer a guy’s story and  its not balanced. It is an honest  taste of the human side of pharmacy. And a sometimes tasteless one at that.

 

***THE BOSS***

In the 1970′s, all the druggists at the pharmacy where I worked happened to be men. The hair was long, the moustaches were handlebar,  and the sideburns were like runways. There was yards of denim, but there were NO lab jackets.  It was the ME decade, not the patient decade.

How many of the hours did my boss work? I’d say ninety percent. Thats just how pharmacy was in the seventies. Eventually his marriage suffered.  The end came  during a matinee showing of  ”Bob, Carol, Ted, and Alice”.  He caught his wife making out with one of the ushers. And the guy who operated the popcorn popper.                                   .

 

 

 

***THE DELIVERY CAR***


OK, this wasn’t our store’s delivery car.  This is what my boss bought himself after his divorce was final.  It was during this period that he actually volunteered to make a few select deliveries for me.  Typically to one of the  lonely, single, lady customers that lived in the garden apartments behind the store.  He would say, “Don’t worry Refills, I’ve got this one”.  It was always the last delivery of the night.  I never asked if he got decent tips.

This was the store delivery car.  It had a unique safety feature: the driver-side door could only open from the outside.  Its air conditioner usually quit by mid-June.  During winter, I would mount a lit Sterno can on the dash to keep the windshield defrosted. In 1977 the car lost its reverse, which, according to the boss, was always an over-rated gear.

 

***THE JARS OF BLUE WATER***

My grandma worked in the drugstore. Some of my earliest memories were of her dusting the giant apothecary jars in the store window. She worked a feather duster over those glass bottles so they would sparkle from the sun.  The jars held a mysterious blue liquid, which was a source of endless fascination for me.  When I was finally old enough, my grandma got me a job there. I was hired to make prescription deliveries.  A “beat-nick looking” guy, who also worked there, trained me.  One day he took me to the side and whispered,  ”Hey Refills, I see you keep staring at the big jars.  I’ll tell you a secret.  They’re filled with the same blue shit that the barber next door soaks his combs in”.  Some time later he was fired under mysterious circumstances.

 

***THE STORE SECURITY SYSTEM***

This tiny little bell above the front door was the store security system. It jingle jangled whenever a customer walked through.  My grandma was the second part of the store security system.  ”Just let any of those little bastards TRY to pull some shit on me”, she would announce.  ”And God Help them if they ask me where the rubbers are. I know all their mothers”.

***THE OVCON***


There wasn’t a lot of variety when it came to prescription medication back then.  And, like I said, the pharmacists were all guys.  So whenever a prescription for Ovcon had to be filled, it was a small event. But that was nothing compared to the diaphragms. Those moments were like side shows. They were ordered by size, so the boss and the beat-nick literally had the customer’s number.

I was pretty near-sighted as a kid and could barely see out by the cash register from where I stood in the pharmacy.  I had only  the reactions of those two guys to rely on.

***THE SECRET CODE AND THE GREASE PENCIL***

When I wasn’t making deliveries I had to check in the drug order.  It wasn’t much of a task. A typical order consisted of a few strengths of Inderal and some Ovcon. Here is how it worked:

When filling a prescription, the pharmacist needed to mark up the price that a customer would pay. It was a secret formula that started with the cost of the item charged to our pharmacy. This cost amount was also a highly guarded secret. So it was marked on each drug package with a code, by me using a black grease pencil.

This was our code:

D=1

R=2

Y=3

M=4

U=5

G=6

L=7

E=8

V=9

I=0

The letters spelled out “DRY-MUG-LEVI”, so it would be easy for the staff to remember.  One year, it was rumored that the code had been cracked by some German customers.  So the boss was forced to changed the code to “WET-MUG-LEVI”.

***THE INFORMATION TECHNOLOGY***

New prescriptions were entered into the latest information processing technology:

It was fairly reliable, except once in the summer of ’77. it went down when half the metal keys got jammed together. For a few minutes we were forced to use the back up system, which was a BIC pen.

.

.

***HOW IT ALL CAME TOGETHER***

On a smoldering heatwave of a day in the  summer of 1977, I was marking bottles of Inderal in secret code with a grease pencil. The boss was reading about some controversy over in the city in the afternoon edition of The New York Daily News.  Our  little bell above the door went jingle-jangle and a few minutes later, beat-nick was taking a prescription from a customer.  He flashed the script at us, so we could  see it was a prescription for Ovcon.  Everything stopped. We all looked up to see one of the lonely ladies who lived in the garden apartments behind the store, standing by the register.  She wanted the prescription delivered. My grandmother cursed in Italian and went up front to look for her duster.

 

The customer turned to reverse out of the store, but I could only make out  her shape, which was Corvette. My boss, the beat-nick, and lonely lady all seemed to be members of the same club, and it didn’t include me. I watched Corvette move down the card aisle but was distracted by the apothecary jars standing in the display window. Summer light shone through them, splashing the front end with waves of sunny blue.

 

The typewriter started its clack clack as my boss typed the label, and the door jangled goodbye. After he deciphered the price from my tiny grease handwriting, the boss turned to me and said, “don’t worry Refills, I’ve got this one”. That was fine with me.  I would rather not worry if I would be able to back the delivery car out of the parking lot.

 

How many of my summer pharmacy days played out like this one? I’d say ninety percent. Thats just how pharmacy was in the seventies.

 

 

by lastrefills on June 16, 2011 (Bloomsday).

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A Defense of a God Complex.

June 10, 2011 – 5:39 am

I almost believe it now. Remove the paddles. I don’t require shock treatments. I’ll say it. Doctors are not gods. They are members of a healthcare team that picks up a patient and moves them down field. Team Healthcare. Nurses, physician assistants, pharmacists, risk managers, adjustors, benefit coordinators, all trying plays. Lets score one for the sicker and try not to turn them over.

But I don’t want to write an essay on how to be a team player in modern healthcare. This is my story of how I came to believe that a certain doctor was kind of a god. Before learned minds knocked the notion out of me. In my youth, the doctors were more than just quarterbacks. They owned the ball. If any nurse or administrator got in the way they would get their helmets handed to them.

Back then my family was medicine monotheists. There was only one doctor that we believed in, Doctor B. My entire family went to one guy. My grandparents, parents, two older brothers, and me all went to him our entire lives for every medical malady. He did everything. He probably delivered us. I know it sounds like I’m from 1905 Kansas, but I’m talking about 1968 New Jersey.

Dr B’s office was in a house and its waiting room was as chaotic as a basement party. There was a big main room with sofas, chairs, and table lamps. Smaller rooms splayed off to the sides with more chairs. Patients spilled out everywhere. Most were glassy eyed kids throwing off temperatures and scared moms. The nervous parents all talked to each other. I don’t remember anyone burying his face in a magazine. They were too restless to stay silent. Vaccination was relatively recent and parents still had fresh memories of horrible illnesses. To them, every cough could be rough business.

To a small boy, Dr B’s blinding white lab coat reached to the ceiling. He had a face meant for Mount Rushmore. It was as humorless as stone. His eyeglasses reflected the lights of his exam room, and I wasn’t even sure if he had pupils. Jars of tongue depressors anxious to gag a four year old stared at me. No shiny drug company posters of how an allergy worked were prominently displayed on his walls. They were spare.

I was relatively healthy, so I only had to go there for the typical childhood reasons; Strep throat, ear infections, good old chicken pox, and mostly vaccines. Like I said, some vaccines were fairly new and they could tear your upper arm to shreds. But you wouldn’t get any sympathy from Dr B. You didn’t get any words at all. He would occasionally say something to my mom in a clipped Connecticut accent. As I grew older there were less and less reasons for my going there, and I gradually forgot about him. I had teenage dramas to act out instead.

Some time between grade school and high school, I gave up connecting with people in a serious way. Everyone preferred a good laugh, and I was damn talented at making people laugh. I could actually hold a room full of people. Except of course my dad. Humor was not big in his vocabulary and I didn’t come with a dictionary that would help him translate me.

I didn’t mind the fact that people no longer expected me to be serious. That is, until I found myself in a serious situation. In the winter of my third year of high school I started not to feel right. For about a week I kept having gas pains. That’s what my parents called them. They were sharp little stabs. They came. They went. They were always in the same place so I got used to them. Then one morning I reminded my mother they were worse.

“Stop kidding around, just go to the bathroom”- she advised.

Later that day, I found myself sitting in Literature class, gripping my desk like it was the sinking Titanic. My sweat was collecting all over my Macbeth. I’m not sure if its possible, but I think I heard a tiny little gun go off somewhere behind my belly button. To this day I refer to it as “the shot heard around my colon”.

“Uh Ma’am, I think I need to go see the nurse” –I said to my Lit Teacher.
“ What now, class clown?” –was her concerned response.
“I don’t think I’m joking this time”. – I replied.

“We don’t appreciate your foolishness. Go on. “

As I walked down the two floors to the nurse’s office, no one commented how I was bent at the waist, my face parallel to the floor.

My parents were both unreachable. Like every one else they both had to work, so, as always, it was up to my grandparents to come through in a crisis. Mine were old world Italian and old world Polish. My Polish grandfather was the one to show up at the school to come get me. And my grand pop, who had never went to high school, out-diagnosed the hell out of that school nurse by just looking at my face. He had no time to listen to her suggestions about Mylicon. He already had me in the car and was driving like a Cossack out of Poland straight to Dr B’s office.

The appendix is a little runt of a tissue that hangs on to the colon. No one is sure if it serves any purpose. People can definitely live without this annoyance. However, if you ignore its tiny little cries, it can burst, leaving a hell of a mess in your blood stream and ruining your future. This situation is known as serious; emergency surgery is indicated, antibiotics will be served.

I barely spent enough time in Dr B’s waiting room to notice that it hadn’t changed in ten years. As always, it was still filled with patients. Even though I could not stand up straight, some one noticed my skin color. It was gray. The mass of people at the front desk parted, and my grandfather and I were ushered to an exam room, and I was in the presence of the white coat again.

There was no long medical history. I don’t even remember getting undressed. I remember Dr B’s finger. Without warning or hesitation he was behind me, jamming his index finger into my ass.

“OK”, I thought, “I will never tell another joke again, just please remove that”.

When I looked around he was pointing his finger skyward. It dripped a shiny dark poison that I had left there. My stomach flipped, but my doctor was already on the phone. The world around me had burst into dark spots and my ears were ringing loudly. I could faintly hear the words “hospital” and “ I will meet you there”. Again, the Cossack drove.

At the hospital, my mom and dad had also arrived. Dr B did not yell at anybody. His clipped Connecticut accent delivered orders in quick short sentences. The staff responded. He led and we followed. Both of my parents were quiet in the background. I wasn’t mad at them; they knew nothing of medicine. But they still felt an awkward guilt and maybe blamed each other a little.

Dr B did not have the time or the training to worry about family nonsense. He knew that none of us had any idea what was happening in my abdomen. He tilted his face down towards mine and the light shifted away from his eyeglasses. I could see his eyes, fully. They were fixed on mine and as he continued to instruct the nurses, my fear eased.

For some reason I thought about his waiting room. I remembered it had been full of patients when I was rushed out of there. What had happened to those waiting patients, did he just leave all the others so he could tend to me? His hand lifted from my foot, I had not been aware that he had placed it there. He turned and left and then I was taken from my parents.

I don’t have reliable memories of the three weeks that followed. The first recollection that I did have following my emergency APPY, was me waking in the middle of the night and trying to remove a tube that had been placed in my nose. I didn’t know it reached all the way to my stomach, and was sucking the poison from there.

Believe it or not, I actually enjoyed parts of my hospital stay. It was a break from the stresses of high school and family. The drugs were wonderful and I slipped in and out of consciousness randomly. One day, the school priest showed up to pray for me, and I pretended to be asleep so he would leave. I pretended to sleep for most visits, actually. But I would always peak from my half closed eyes hoping I would see Dr B.

I’m sure I had some follow up visits, but I don’t remember them. There was no handshake or parting words of wisdom. His gift of a continued life was plenty. Young adults only go to doctors in crisis and he had just delivered me through mine. He was needed elsewhere.

I spent the earliest part of my late teens and twenties uninvolved with the medical profession. And then came the days that I was wandering in between colleges, the map to my future still not unfolded. Typical of me I found something less useful than true commitment to serve as a distraction. I became slightly obsessed with obtaining the medical record of my high school emergency.

All my requests were answered with polite apologies. The hospital had long since merged with another. The original building flattened. Dr B was retired and perhaps passed on. I had begun to doubt parts of my own story of him.

The image of his mountain face remains. Even though I don’t remember seeing him during my recovery, he was checking up on me and communicating with my parents. Honestly, he had done the important part when he locked eyes with me in those moments before the surgery. He had been leading me. He wouldn’t ever tolerate me looking into a valley.

I never recovered a copy of my chart. The hospital record remains my rosebud grail. I hunt for it in my mind. I don’t know why. Would it bandage some unclosed wound? Would it steady some rocky memory? In doctor B’s notes would I finally read the word of a savior?

Written by @lastrefills. June 5, 2011
Can comment to @lastrefills on twitter.  ∞

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