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Unruly Patients

It ain't easy working retail. The vast majority of pharmacy patients I've served are no problem. A few are great, and a handful are your favorites. On the bell curve of the patient population, however, for every favorite, there is a very difficult patient. Don't mistake my choice of words as a weak vocabulary or unimaginative adjective selection. In the pharmacy setting, I'm a professional, folks, and I refuse to let my thoughts about any patient become negative in such a way that it would compromise my ability to treat them. As a medical professional, I don't care who you are; if you're my patient, you're entitled to a standard of care, and you'll get it, even if you pull a stunt like a patient recently did to a pharmacist I work with.

She's always been a difficult one, revving her engine in the drive-thru and peeling off through the four-way stop without stopping. I haven't begun relating the things she's said, but suffice to say, if you heard her, you'd think everyone in the pharmacy spent their day devising devious plans to make her day miserable.

To wit, after a recent change in her insurance plans, she was left without prescription coverage during the last week of the month. Those of us in the pharmacy are merely the bearers of bad news, a responsibility we loathe, because those are the times you see either the best or the worst in your patients. Whenever I have to relay such a message, I put myself in the patients' position and consider how I'd feel in such a situation, and go from there. I'm sympathetic, encourage them to call their insurance company, and often times have already called the insurance company myself to investigate.

Some folks understand we're not the bad guys. Some folks need to vent, and the pharmacy employee standing in front of them is way more accessible and timely than the insurance company's customer service line, so guess who gets it? That's right, the tech or pharmacist who just dropped everything else to try to resolve the situation with the patient's insurance company, or maybe someone who just started a shift and has no knowledge of the situation other than the handwritten sticky note on the receipt.

Anyway, our patient peeled out of the drive-thru, and the patient's insurance company called the pharmacy. The patient was on the other line, and the insurance company rep told the pharmacist, "We need to get her re-enrolled, and fast." I can only imagine what she said to the poor rep that persuaded him to call us at the pharmacy, because that's so untypical of an insurance company. So the pharmacist waited on the line, resubmitting the prescription claim multiple times until the rep properly re-enrolled the patient so that her claims no longer rejected, and she was able to fill prescriptions before her policy's official activation date.

Apparently, the patient wasn't aware of the pharmacist's assistance. The next morning, the store manager told the pharmacist she had filed a tearful complaint against him, and threatened to take the matter to corporate. She claimed he was refusing to fill her prescription and had been very rude. You know, I was there all three times she came through the drive-thru window, and the only person who had been insulting, the only person who had raised their voice, the only person who had rolled up their car window and turned up the volume on their radio while the other person was trying to speak, was the patient. The limit of the pharmacist's confrontational behavior was to offer to transfer the patient's prescription to another pharmacy of the patient's choice when it became apparent she could not be satisfied.

So, here is what I would ask of you. If you go to the pharmacy someday and they tell you there's a problem filling your prescription, please keep a few things in mind:

  • Your pharmacy does not tell your insurance company what to do. It's the other way around.

  • The advice we give you is sound advice. If we could have resolved the issue, we would have done so before you returned to the pharmacy. If you're having an insurance problem we can't resolve, odds are, you've had another problem at some point we were able to resolve without you ever knowing about it. We deal with insurance and prescription problems every day. We're not just drug experts, we're insurance experts, too.

  • The pharmacist and other employees derive their livelihood from dispensing medications. They need you and other patients to put food on their tables. Without you, they don't get paid. Therefore, it is in their best interests to help you get your medicine.

  • Your insurance company derives its livelihood from limiting healthcare expenditures. When problems arise with the cost of your medicine, or you're told your medicine requires something called a "prior authorization" from your physician, it's your insurance company, not us. Your insurance company is trying to keep your premiums low and make a profit.

  • Do you blame the television reporter for all the bad in the world they tell you about on the evening news? Please don't blame us when we tell you there's a problem filling your prescription. Remember, if you don't get your medicine, we don't get paid.

  • We're on your side, and want to help. It's a lot easier for everyone involved if you help us help you.

:: Bryan Travis :: 10/29/2006 @ 22:15 :: [link] ::

Adventures with Parasites

Adopting a barn cat from a farm with a large population of cats is sure to familiarize you with one thing: parasites. This is something we learned from our new kitten, Zoe, a calico we adopted from Cynthiana. I suppose the same could be said for adopting dogs, stray animals, and even people. Anywhere a population of animals is living in close quarters with others, is a paradise for parasites.

Parasites are masters of finding niches, and there appears to be no limit to their morbid success finding ways to exploit their hosts. Blood suckers like fleas, ticks, chiggers, and mosquitoes are just the beginning. Even though they rob us of our living-giving fluid, blood, they don't make us cringe like some others do. Lice, for example... now, there's a parasite that literally makes your hair tingle. Bedbugs, also an aversive bug, pale in comparison to kissing bugs, which add injury to insult by being two parasites in one. Kissing bugs suck blood from a sleeping victim (they prefer the face, hence their name), and then poop on the bite site when they crawl away. In the feces is the protozoan parasite that causes Chagas disease, which is implanted when the victim scratches the wound, eyes, mouth, or nose. Yeah, that dump they take when they crawl away strikes me as brazen disrespect, the ultimate calling card.

Then there are ear mites, which our kitten Zoe had, finally eradicated after repeated treatments with pyrethrin ear drops. These aren't so bad as kissing bugs. They burrow into the skin in the ear canal, drink some blood, cause severe irritation and itching, and then something else they do turns the host's ear wax black (I guess pooping), which is one of the hallmarks of ear mite infection. The other hallmark is placing a bit of that black ear wax on a dark background, smearing it, and carefully or microscopically observing the tiny, white ear mites as they crawl away. Kinda gross, eh?

A couple roundworms our kitten puked up. Dee-lish!But perhaps the most repulsive parasites of all are the intestinal worms. Everything about them makes you say, "Ewww." They live in the intestines, with digested food and poop, feeding on the host's intestinal lining and robbing nutrients. Eggs are transmitted via the fecal-oral route; that is, one infected host has eggs in its poop, and an uninfected host somehow gets an egg in its mouth and swallows it.

Just think that one through. Apparently, fecal-oral transmission occurs more often than we'd care to think, because evolution has determined it happens often enough to be a reliable strategy for supporting the lifecycles of most intestinal parasites. Delicious!

Our Zoe has roundworms, and we're not sure of the exact species. Toxocara cati lives exclusively in cats, except for the larvae, and I'll get to that tasty part in a bit. The other, Toxacaris leonina, can infect and develop in multiple host species.

The T. cati roundworm lifecycle is fascinating. They lay eggs that pass in the cat's poop. The eggs spend about a month developing in the environment, and then can wait for years for a mammal to eat them. If the eater is a cat, the eggs hatch in the intestines, the larvae burrow into the tissues, and usually encyst in the liver to develop. Next, they emerge from the cyst and enter the placenta of unborn kittens or the milk of nursing cats to transmit from mother to kitten, or the larvae go to the lungs, get coughed up, swallowed, and develop into adults in the intestines, which lay eggs that are pooped out.

If a host other than a cat (known as an intermediate host) eats a T. cati egg, the larvae hatch in the gut, burrow into the tissues and usually encyst in the liver, but not always. Lucky larvae develop in small mammals that a cat will eat, such as mice, rats, small bunnies, or chipmunks. The larvae's burrowing behavior is a problem for humans, because the larvae can burrow into the eye and cause blindness, the brain and cause seizures, or severe inflammation wherever else they go. Fortunately, the vast majority of the time, the larvae burrow in the liver, and that's the end of it. The really tasty fact is, if you have ever had a cat that goes outside and comes into your home, there is an excellent chance you have worm larvae encysted somewhere in your body. Same goes for toxoplasmosis, which is a single celled protozoan, not a worm. Basic message: you don't want to be an intermediate host, because the larvae can mess you up. Being a definitive host to adult worms is actually better, notwithstanding the "ewww" factor of worms slithering around in your poop.

T. leonina roundworms lay eggs that pass in the host's poop. The eggs develop, and the lucky ones are eaten by some mammal and develop into adult worms. Thus, humans can be definitive hosts for T. leonina, with adult worms in their intestines. This is ultimately delicious, but wormy parasites typically do less damage to definitive hosts than intermediate hosts, because as gross as the adult worms are, it's the burrowing larvae that can do the most damage.

So, we're not sure which species our young Zoe has, but I kind of wish we did. When we first got her, the vet found and treated her for roundworms, but because we didn't understand the lifecycle, we didn't ask about a second roundworm treatment, and the vet didn't offer. Because you see, a roundworm medicine only treats the adult worms in the intestines (and it doesn't even kill; it only paralyzes worms so they lose their grip on the intestinal lining and pass on through). Any larval worms hanging out in the liver or lungs are unaffected, so roundworms can re-establish unless the cat has two or three de-worming courses about two or three weeks apart.

The night before we re-discovered Zoe had worms, I drank a latte while studying for tests. I put the large latte cup on the bathroom counter, studied some more, heard Zoe jump up on the counter, but thought nothing of it. Later that night, I rinsed the cup out with water, and drank from it. Then I watched Zoe walk over to the cup, lick the inside of it, stick her paw in it, then walk away.

Thinking about all the times I've watched her lick her butt or play with "things" inside the litter box, I was grossed out. When Zoe jumped up on the bathroom counter, before I drank from my cup, she may have licked the inside or stuck her paw in it. I'll never know, but when she puked up a few roundworms the very next day, I wished I had known. Better yet, I wished I hadn't drank from that cup without washing it better. Hopefully, she didn't leave a worm egg for me inside my cup, but if she did, hopefully it was T. cati, because I'd really hate to find adult roundworms in my poop in a couple more weeks. Aside from the shock of seeing wriggling worms in my poop, I'll be really embarrassed if I have to go to the pharmacy where I work (or any pharmacy, for that matter), and present a prescription for mebendazole, explaining that I caught roundworms from my cat.

Maybe I'll just lie and say I caught pinworm (although that's a one day course of mebendazole, and roundworm is a 3-5 day course... however, it would take a keen pharmacist to catch that), because pinworm eggs spread through the air, and it's entirely feasible and easy to inhale a few from a passing stranger who stirs up pinworm eggs from their clothing. Here's a short video from a colonoscopy showing a pinworm infestation up close and personal. Enjoy!

:: Bryan Travis :: 10/19/2006 @ 02:20 :: [link] ::