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:: Friday, October 29, 2004 ::
The Kentucky State Legislature failed to pass a budget in the 2002 and 2004 sessions or restructure Kentucky's growth prohibitive tax code in the state that ranks 44th out of 50 for business-friendly tax climates. This state would rather keep giving favors and buyouts to tobacco farmers when it's obvious tobacco isn't the cash crop it used to be and such money would be better invested moving Kentucky out of the Stone Age. Meanwhile, the Kentucky Legislature Home Page prominently displays a link to the "Proposed Marriage Amendment" that would define marriages in Kentucky as being between a man and a woman. This is a ballot referendum for Kentucky voters on November 2.
Dear Sirs and Madams of the Kentucky Legislature, please stop wasting my tax dollars invading people's bedrooms and focus on important issues like passing a state budget.
Such performance is pathetic and inexcusable, from Democrat and Republican alike. When I worked at GE, my manager and I would create and agree upon a list of objectives for me to complete. In exchange, I received a paycheck, continued employment, and, depending on the business benefit of my results, salary increases. If I didn't complete these objectives or my results were unsatisfactory, I would have been told my services were no longer needed.
I wish the legislators' salaries could be withheld. The primary objective of the state legislature is to pass a state budget. Failure to do so is a dereliction of duty and should be grounds for dismissal and suspension of pay. This disconnect between how our society functions and how the legislators perceive their duty to the citizenry of Kentucky is precisely why they're worthless as legislators.
On November 2, I'm voting against all incumbents in the state legislature. Not every legislator is out of touch, so yes, I'm purposefully making uninformed voting decisions. My reasoning is that if the state legislature can't pass a budget, it's because the majority of the legislators are incompetent, so voting against all incumbents will yield fewer mistakes than voting to keep them, since (qed) most incumbents are incompetent and out of touch.
So Senator Tom Buford (R) and Representative Stan Lee (R), this is an easy one... I think you both should be fired. Most incumbents win re-election, so neither of you is probably in any danger, but I wish voters would send all 137 of you in the state legislature home when you terms ended.
You'll notice that beginning with the third item on every legislator's bio page is their religious affiliation, followed by their extracurricular activities. Personally, I don't see the relevance of either. I thought separation of church and state was supposed to prevent religion from meddling in governmental affairs, but hey, this is Kentucky, where marriage laws take priority to the state budget. As for the extracurricular activities, this election is for the state legislature, not the local school board or class president, so show me your platform or voting record, not your involvement with the local 4-H or Kiwanis Club.
And that's all I have to say about that.:: Bryan Travis :: 10/29/2004 @ 18:59 :: [link] ::
:: Wednesday, October 27, 2004 ::
Dear Pharmacy School Diary,
A 3 year-old child with congestive heart failure presented a prescription for digoxin elixir in our fourth pharmacy lab. Unfortunately, the pharmacy was out of commercial digoxin elixir. Whenever the inpatient hospital pharmacy I volunteered at ran out of a medication, they attempted to procur it from another hospital pharmacy; the other pharmacies, in turn, called my pharmacy when they ran out of something. That's called "partnership."
The pharmacy school does not borrow medications from other pharmacies. No, sir. When we run out of digoxin elixir, we compound our own from triturated digoxin tablets, propylene glycol, carboxymethylcellulose, and cherry syrup.
Fortunately, the compounding procedure is printed on the prelab worksheet, and we calculate how much drug and suspending agent are needed and specify the proper compounding equipment to use. Each prelab has less information than the one before it. Eventually I expect to walk into lab, find a prescription and blank compounding form at my bench, and be wished all the best in preparing it. Since I want to be a pharmacist, this seems a reasonable expectation. Nevertheless, it terrifies me for some reason... perhaps because the lab instructor ruthlessly deducts points for minor mistakes, and with no printed instructions for guidance, mistakes are virtually guaranteed. Hmm, yes, I think that's pretty much the issue.
Digoxin was originally derived from the foxglove plant. Digoxin inhibits plasma membrane sodium and potassium ATPase pumps, thus acting as a diuretic and slowing the rate at which cardiac sarcolemma repolarizes itself to resting potential, allowing sarcoplasmic calcium ion concentrations to remain elevated, which prolongs and strengthens heart contractions. Unfortunately, the therapeutic dose for CHF is dangerously close to the lethal dose, so serum levels are carefully monitored and digoxin immune fab is used for overdose.
Inscription: Digoxin 10 mcg/ml
First the calculations:
Next is the compounding procedure:
We also write patient counseling instructions on the worksheet in sentence form, as if it were a script for Act Three, Scene One of a play in which a parent goes to the pharmacy to pickup a digoxin prescription for their child and the pharmacist gives the following monologue in true Shakespearan fashion:
:: Bryan Travis :: 10/27/2004 @ 06:40 :: [link] ::
:: Saturday, October 23, 2004 ::
After the last test of the second round of block exams, I came home and hung out in the crawlspace for three hours digging new trenches to the sump pump well. I was burning fumes on only two hours of sleep, so I'm not sure where the energy came from. Maybe I took it out on loan, and payback day was spread over the next two days, because I certainly felt it then. My gluts hurt, too... odd how spending three hours with a shovel on your hands and knees can make your ass cheeks sore.
Water collects against two foundation walls in our crawlspace. Standing water in crawlspaces is never a good thing, and as my neighbor across the street remarked when I told him about it, "You can't be a dumbass about things like that; you have to take care of it." I stood there thinking, I think this joker just called me a dumbass, which was a find how-do-you-do since this conversation took place when I returned his dog food and water bowl after dogsitting for him over the weekend. That's gratitude, I guess.
When water collects somewhere, it's because it doesn't have anywhere to go. It's not rocket science: you make like it's Saturday night and find someplace for it to go. In my case, I wanted it to go to the sump pump well in the opposite corner of the crawlspace.
When the house was built, the crawlspace seemed to have been designed properly, because for the most part, the landscape in there tends to slope in the general direction of the sump. But over time, some areas have settled or otherwise become isolated and began pooling water. The soil in parts of the crawlspace is like clay, so it's no wonder water collects. If it can't drain along the surface, the clay prevents it from percolating down, and the vapor barrier prevents evaporation, so it just sits there like the geeky kid on prom night (I should know - I was the geeky kid).
My neighbor told me our lot was the last to be built, so it was the "junk lot." That means the scraps and excavated soil from the other houses ended up on our lot. Joy. Most houses with a concrete porch or patio have some scrap underneath all that concrete. Ours probably has more than average, and wouldn't you know it, the water was collecting at the foundation wall next to the porch. Our next door neighbor had termites several years ago and has regular treatments; diffusing termiticide probably protects our house now, but I guess it was pure luck that our house wasn't infested first.
So there I was in the crawlspace, digging trenches to drain water, reliving moments from my childhood. I remember my brother and I digging trenches in the backyard at the border of the garden and using water from the swimming pool to send rushing torrents down the channels and create lakes. I was doing the same thing in the crawlspace, but on a slightly larger scale and with our house at stake.
The trick is to dig the trench deep enough so it won't clog with mud and sediment too quickly. You also have to dig it gradually deeper as you go along so water will flow, but not so deep that it's deeper than the final destination, which is the trench leading to the sump well, or you'll end up spending weeks in the crawlspace redigging all the friggin' trenches.
I dug the trench first, leaving a few inches of soil between it and the pooling water, then removed the soil wedge allowing the water to flow all the way to the sump trench. In the first two hours, the sump kicked on once, but in the third hour after the water began draining and I started digging to the second pooling area, it kicked on nine times. Wow, that was a lot of water.
There's another area of pooling that's been partially drained, but the problem is digging a new trench that doesn't get deeper than the original trench leading to the sump pump well. As I began working to drain the second pool of standing water, the shovel hit something hard. Whenever the shovel scraped away the gravel and mud, the soupy mud quickly hid it again. So I plunged the shovel into the mud to determine the perimeter of this object. It was a 4' x 3' rectangular object buried about 2 inches in the mud. Hard to make it out, so I wedged the shovel underneath it and pryed it up. It was a large, flat piece of plywood. A smell like a horrible fart spread throughout the crawlspace. Buried in the soupy mud under the vapor barrier, the lack of oxygen allowed anaerobic decomposition of the wood, and what I smelled was methane with an assortment of other fermentation byproducts.
The large piece of wood was part of the drainage problem... maybe it was intended as an appetizer for the foraging termites contemplating an invasion of our house. Furthermore, if the original trench had the proper drainage pipe in it instead of only gravel, it wouldn't have slowly filled in over time and I wouldn't have this problem digging a proper trench. On further consideration, I probably wouldn't have dig trenches in the first place and spend so much quality time in the crawlspace.
Ah, a moment a clarity... if the crawlspace had been done properly in the first place, I wouldn't have to be here. This is when you curse the person who masterminded this crappy crawlspace drainage in the first place, but alas, if you're the fifth owner of a 15 year-old house, you have no idea whodunit and little hope of ever finding out.
What to do? Well, you deal with it, congratulate yourself on your own trench-digging ingenuity that a subsequent owner will probably curse you for since you're really just a rank amateur like the original crawlspace trencher, and move on. Except this time, you install the proper drainage pipe.:: Bryan Travis :: 10/23/2004 @ 19:22 :: [link] ::
:: Tuesday, October 19, 2004 ::
The upcoming antibiotics test is guaranteed to suck like the vacuum of space. Imagine a huge grid, like a chessboard, only much larger. Running across the top are the names of bugs; running down the side are names of drugs. Each grid block indicates the effectiveness of the drug on the bug, and why it is or is not effective. That's what we're up against.
The strategy is to recognize patterns. For example:
Each successive generation of penicillins and cephalosporins has increased antimicrobrial coverage.
But it's not that easy. Another pattern to recognize is that every pattern has exceptions... an anti-pattern, if you will. I refer to the anti-pattern of successive penicillin and cephalosporin generations as the "Role Playing Game Character Phenomenon": an RPG character can have intelligence, charisma, or strength, but never all three. In terms of antibiotics, drugs can have broad spectrums or resistance to bacterial resistance, but not both. While each successive generation of cephalosporins has broader Gram Negative activity, the Gram Positive activity decreases... and while each successive generation of penicillin drugs has a broader Gram Positive and Gram Negative spectrum, bacterial resistance develops more quickly.
Why develop successive generations of antibiotics? In a nutshell, because bacteria can take whatever chemicals medical science throws at them and still come out on top. But let's look approach the question from a specific drug class such as the penicillins.
The first commercial penicillin was Penicillin G, but like many innovator products, it wasn't perfect. Some of it's weaknesses (many of which also affect other penicillins):
As I try to figure out a logical approach to describe the 22 penicillin drugs, I realize just how daunting the material is. I'm suffering a mini-panic attack as I type. But since my wife and I are paying $10,000 a year for my pharmacy education, I will try, dammit... yes, I will succeed!
This would bore you senseless, so I'll save the bandwidth. You can go to another website if you like, and leave me to suffer alone in a hell of my own making. And when you come into my pharmacy someday with a 250mg amoxicillin prescription for the third middle ear infection your child has had in as many months, even though you abandoned me in my time of need, I will still take time out to counsel you about your child's ear infections and offer to call your pediatrician to have the prescription changed to Augmentin because I think your child has an amoxicillin-resistant infection. Yes, yes I will... and I won't push you over the edge by asking if you've waited 2 days to see the earache resolved on its own. So run along, and let me be.
But I will say this: mnemonic devices to the rescue!
Amino penicillins (ampicillin, amoxicillin, bacampicillin) are SHEEPS: Salmonella, Haemophilis, E. coli, Enterococcus, Proteus, Shigella.
Piperacillin, a 4th Generation Penicillin, is a KEEPS: Klebsiella, Enterbacter, Enterococcus, Pseudomonas (with an aminoglycoside), Serratia.
1st Generation Cephalosporin SPEAKS orally, not fragily because there is no SPACE: Streptococcus, Proteus, E. coli, Anaerobes, Klebsiella, Staphylcoccus... oral anaerobes only (not Bacteroides fragilis), and not SPACE bugs (Serratia, Pseudomonas, Acinetobacter, Citrobacter, Enterobacter). Yeah, that one's a stretch.
:: Thursday, October 14, 2004 ::
The second round of block exams approaches. The bears will be antibiotics, physiology, and the pharmacy practice class. Usually the pharmacy practice class isn't so bad, except this is the first test with a section on the top 200 prescribed drugs. Since any info about the five drugs we're responsible for is fair game, the new section is an unknown variable, and therefore, a stressor; fortunately, though, the five drugs are antibiotics, so there's overlap with the antibiotics course.
I scored 100% on the first antibiotics exam, and that's a good thing, because I'll need the point buffer going into round two. Yes, it's going to be B-A-D, and those aren't the answers to the multiple choice section of the test. For example:
Q: Which of the following bacterial species are members of the Enterobacteriaceae family?
A: All are Enterobacteriaceae, except for Enterococcus faecalis.
You probably saw "Entero-" and thought Enterococcus was an Enterobacteriaceae, right? WRONG, but hey, thanks for playing! Shakespeare had it right when he asked what's in a name, because the key to mastering microbial binomial nomenclature is not in the names... it's a paradoxical and perilous road fraught with misadventure. If Shakespeare wrote a play about bacteriology, it would be a tragedy. There are no comedies when it comes to bugs and drugs. Enterobacteriaceae are Gram Negative aerobic rods/bacilli. Cocci such as Entercoccus, Neisseria, and Moraxella are not Enterobacteriaceae; anaerobic rods such as Bacteroides are not Enterobacteriaceae... but the following genuses are Enterobacteriaceae, and don't you ever forget it: Morganella, Escherichia, Shigella, Salmonella, Yersinia, Serratia, Proteus, Enterobacter, Citrobacter, and Klebsiella.
Here's a mnemonic for Enterbacteriaceae: MESSY SPECK.
If there is any light at the end of the antibiotics tunnel, it's the miracle of mnemonic devices.
But that's nothing... it gets better, believe it or not. For example:
Q: How many mEq of potassium are in 3 million units of Penicillin VK?
How does one determine that? You're probably thinking hell if I know!, and I'm with you. It's just one of those conversions we memorize for tests and depend on our drug reference books and software to remind us in practice, not unlike the conversion from units to milligrams of various penicillins. Sigh.
Q: What is an effective treatment for oxacillin-sensitive Staphylcoccus aureus? Penicillin GK, Nafcillin, Both, Neither?
Q: What can be used to treat a Bacteroides fragilis infection? Piperacillin/Tazobactam, Ampicillin/Sulbactam, Both, Neither?
Make it stop! Please, make it stop!
I'll spare you the details of alpha-1, alpha-2, beta-1, and beta-2 adrenergic receptors in the sympathetic autonomic nervous system, and which sympathetic nerve endings are exceptions because they are muscarinic or nicotinic acetylcholine receptors. But how I wish I could spare myself from learning those details, too.
Yes, life will be stressful this week! More or less as an afterthought, we're responsible for the rest of the common medical abbreviations:
m = mix
Meanwhile, one of the cats is sitting in the window licking her butt for all the neighbors to see. Public displays of ass-licking may trump block exams on a list of things I wouldn't want to do.:: Bryan Travis :: 10/14/2004 @ 04:56 :: [link] ::
:: Monday, October 11, 2004 ::
I created a new category (Pharmacy Phables) in the "::..archive..::" section for pharmacy school posts since I seem to be writing so much about it lately. Included are our weekly compounding lab adventures, moaning about block exams, and my admission essays that may (or may not) be helpful examples for other pre-pharmacy students and applicants.:: Bryan Travis :: 10/11/2004 @ 23:54 :: [link] ::
The Livermore, California city council agreed to pay $6,000 for airfare plus expenses to the artist who misspelled 11 names on the mural she created in front of the new Livermore library. The artist, Maria Alquilar, blamed the misspellings on the city council, and everyone else who viewed the work-in-progress mural, for not bringing it to her attention. Then she went on to say the misspelled words would "register correctly" in the eyes of enlightened people. After receiving complaints from all over the country, Alquilar now says she won't fix the mural because of "the abusive attacks against her and her work."
Frankly, she should be paying the airfare, but if she absolutely can't afford it, okay, that's fair... but $6,000??? For that much, she must be flying first class; if it were me, I'd offer to fly Southwest. If she quit trying to abuse the system and flew with a $400 coach ticket, maybe the Livermore taxpayers footing the bill and everyone else who's not from Livermore wouldn't abuse her.
Hey, Livermore City Council, listen up! Save the airfare and find someone local who's willing to fix the mural. Since it's such an eyesore to the community, there are probably plenty of people who'd even do it for free! Maria Alquilar's career is over, anyway. She's cut off Livermore, so why not cut her off and fix it on the cheap?
Any professional who doesn't have enough pride in their work to 1) ensure quality or 2) maturity to accept responsibility for their mistakes and correct them is a disgrace to their trade. Maria Alquilar cannot admit to her mistakes and has resorted to acting like a child. By refusing the fix mural, she has let her detractors win and proved their point.
I was an Information Technology professional in my previous life. On several occasions (more than I'd like to admit) I made mistakes that impacted business operations. I didn't blame my mistakes on aggressive timelines or having to do the work after hours when my thoughts turned to fuzz. I took responsibility and did whatever was necessary to fix the problem. Sometimes that meant leaving work at 3:00am and coming back at 7:00am to fix it... followed by applying Vaseline to my ass before the inevitable post mortem meeting that was sure to follow. Other times I saved a lot of embarrassment by applying the old adage "measure twice and cut once" to my work.
In my next life, I hope to be a pharmacist, where the stakes are even higher. In I/T mistakes meant missed timelines or lost productivity. In pharmacy, at best, mistakes result in sub-optimal treatment of symptoms and disease states; at worst, mistakes lead to death.
So forgive me if I seem insensitive to Maria Alquilar's plight, because the world I live in has always held me accountable for my successes and failures, and I have this strange way of assuming she should be held to the same standard.
:: Sunday, October 10, 2004 ::
:: Bryan Travis :: 10/10/2004 @ 18:16 :: [link] ::
:: Friday, October 08, 2004 ::
Dear Pharmacy School Diary,
We prepared a suspending agent stock solution and compounded a suspension medication for a dog in our third pharmacy lab.
Pharmacy lab introduces us to substances with peculiar physical properties such as suspending agents. When compounding insoluble drugs or when solubility isn't known, pharmacists mix drug powder into suspending agents to make suspensions. The problem with suspensions is that the drug particles sink to the bottle of the container. You can use "Stoke's Law" to describe this phenomenon and utterly fail to impress the opposite sex, or you can intuitively appreciate that suspensions with small drug particles and viscous suspending agents take longer to settle out than large drug particles and thin agents (which is a good thing), and use all that time you've saved not learning Stoke's Law to triturate drug powders and mix up viscous suspending agents.
Methylcellulose is a common suspending agent. As a fully prepared suspending agent, it has the consistency of unchilled, unset Jell-O. But after adding the first portion of hot water to dry 1500 cps methylcellulose, the resulting goo was indistinguishable from ectoplasm, the snot-like slime in Ghostbusters ("he slimed me"), if you're old enough to remember that flick. Peculiar!
We admired our suspending agents until...
A dog with CHF (congestive heart failure, since you don't have to learn the common medical abbreviations below) trotted into the pharmacy with a prescription in mouth for an Enalapril suspension (1.14mg/mL) in beef bullion. No joke. (Note to self: dog saliva could be a promising suspending agent.)
It's a damned good thing he came when he did, because it would have been a shame to let all that suspending agent go to waste.:: Bryan Travis :: 10/08/2004 @ 19:19 :: [link] ::
:: Tuesday, October 05, 2004 ::
This rumor that the Bush administration will reinstate the draft if it wins a second term is a funny thing. Young adults in urban areas and college campuses are registering to vote in droves. We presume they're registering to vote for Kerry. There is a senate bill and house resolution to reinstate the draft, seeking to require two years of military service. They will both be crushed, but it's interesting to note Democrats introduced this legislation. They didn't do it to start the rumor (the proposed legislation has been around for a while, but the rumor is relatively new), but because they wanted to make a point (everyone knew the bills would be defeated): the U.S. military is strapped for personnel, and continuing to stretch the Reserves as thin as it is today will cause more to leave.
Will the draft be reinstated? If Bush wins, almost definitely. If Kerry wins, probably... unless Kerry makes good on his claim to appeal to our allies for additional troops. If Kerry is elected president, there will be a flood of goodwill from the Bush-weary world community and UN, but I can't imagine it sufficient to commit the 10,000+ troops needed for the long haul.
I'm voting for Kerry, but I think the Bush administration has dug the United States into a deep hole. Reelecting Bush will dig it deeper, and electing Kerry will halt the shoveling, but will leave the problem of the hole to contend with. For example, even with a new president, the U.S. must contend with a record deficit, rolling back the tax cuts the government cannot afford, the need for a draft to maintain the joke that passes for the Iraqi interim government and elections, a Muslim world that's pissed at the West and cranks out extremists faster than it ever has, a looming energy crisis, nuclear weapons programs in North Korea and Iran, and an insolvent Social Security System.
Basically, even under the best circumstances I don't see how Kerry can emerge in a positive light. And if Bush wins, he'll be so unpopular on his way out that the Democrats will sweep an easy victory, but will leave behind a legacy of extremist federal and Supreme Court judges that will turn over decades of progress in civil rights. Good ole Rehnquist... he's a good sport for hanging on and trying to outlive Bush before resigning.
Damned if we do, and damned if we don't - I'm such a cynic!:: Bryan Travis :: 10/05/2004 @ 18:47 :: [link] ::
:: Friday, October 01, 2004 ::
The tears were streaming down my face after reading about this physics class experiment with natural gas, a balloon, a buffoon, and fire gone awry. The story was posted by Bryan Travis, but that's not me... coincidence.:: Bryan Travis :: 10/01/2004 @ 18:03 :: [link] ::