Flu Vaccine or Fired

As hospital healthcare professionals, we stand at the frontline of patient care of very sick patients.  Our patients include those with cancer struggling with an infection, patients on the ventilator with sepsis and the list goes on.  Where does personal liberty end and responsibility to our patients begin? Eight employees were just fired from Indiana University Health Goshen Hospital in Goshen, Indiana for refusing the flu vaccine.

“As a hospital and health system, our top priority is and should be patient safety, and we know that hospitalized people with compromised immune systems are at a greater risk for illness and death from the flu,” explained hospital spokeswoman Melanie McDonald to the Elkhart Truth. “The flu has the highest death rate of any vaccine preventable disease, and it would be irresponsible from our perspective for health care providers to ignore that.”

Amen and amen.

First do no harm reminds the health care providers that they must consider the possible harm that any intervention might do. It is invoked when debating the use of an intervention that carries an obvious risk of harm but a less certain chance of benefit.

What about the harm of possibly transmitting the flu virus to a patient?  Yes, there is an argument that the flu vaccine doesn't always cover every strand of flu of the current year, but even in my case this year I was the one in my home that did NOT get the flu.  My husband and son were not vaccinated and they tested positive for Influenza A.  I know it's not always effective, but this year the going percentage I am hearing is 60% effective.  That is significant.

Among those who do have symptoms when they get flu, they may be shedding the virus up to 24 hours before the onset of symptoms.

American Academy of Pediatrics (AAP) became the latest organization to issue a policy promoting mandatory immunization against influenza for health care workers, with exemptions for health reasons. In July and August, the Infectious Diseases Society of America (IDSA) toughened its policy on flu vaccination for health care workers by removing an exemption for religious reasons and specifying that annual vaccination should be a condition of employment in health care settings and/or a requirement to receive professional privileges. The Society for Healthcare Epidemiology of America adopted a similar policy. In November 2009, the National Patient Safety Foundation had voiced its support for mandatory vaccination of health care workers.

My stance?  If you refuse the flu vaccine and work in a hospital, find another job.  You are putting your patients at risk.  Egg allergy?  Read this.

Pharmacy Residency or Not?

If you were a manager or director of a hospital pharmacy, what candidate would be the most desirable for your team:

1. A fresh-out-of-school pharmacist who just passed the boards
2. A fresh-out-of-school pharmacist a year ago that just completed a residency
3. A seasoned 5-10 year pharmacist in the same type of pharmacy

This is the question I have been thinking about in the past few months, and a follower here has mentioned I should do a post on it and try to lend some insight without bias.

That's the hard part because I fall into category 3 and you can better believe that I truly believe the seasoned 5-10 year pharmacist has a lot over the other two.  So, can I do this without bias?  At least I have gotten my opinion out of the way.

The pharmacist that just passed the boards is likely to have the most up-to-date knowledge at his/her fingertips... or rather brain.  He or she more than likely has just memorized a plethora of information since we cannot bring Lexi-Comp or any other reference into the boards exam to help us pass.  But is it true that knowing information is very different from applying it in practice?  I remember graduating with that same idea of knowing my stuff but the job I chose helped me quickly forget about 80% of what I learned (retail).  I did not need to know sterile technique.  Gone.  I memory dumped everything about IVs and anything else that I could and focused on classes of drugs commonly used in retail, the side effects, the interactions and giving flu shots.  I obtained my immunization certification and let those that graduated with me that wanted to do a residency to go for it.  Heck, they were making $40K to my 100K.  Seriously.  Easy decision with Sallie Mae knocking on my mailbox monthly for her piece of the pie.  I wanted a bigger pie to have left for ME.

The new grad has the knowledge, but the application is not there yet.  That's my point.

The residency trained pharmacist, on the other hand, has had the knowledge memorized and hopefully had the opportunity to apply that knowledge surrounded by professional pharmacists who helped them to grow both in learning and application.  It really depends on where you did your residency, but yes.  If you did one, kudos to you.  Would I do one now if I could do it all over again?  YES and YES.  Sorry, my opinion that your last rotation of clinicals being equal to a residency is not.  To arrive at a facility for one month and to move on doesn't even get you started on the nuances of the place much less dealing with the different personalities of physicians and nurses.  It doesn't matter if you did the same work as the resident.  He/she will be there for awhile.  It is just different.  Plus, they are sacrificing about 80,000 in pay probably.  Maybe less.  It is just different.

The seasoned pharmacist.  Big sigh.  He/she could be really over it, could be the type that wants to do more (me), or could just really be doing what they love.  The neat thing about experience is that it is priceless.  A pharmacist that has been in the field for over 20 years really has an appreciation for it all.  Yes, they may have moved on past order entry and clinical floor work.  They may be in management at this point, but some remain in a operational/clinical role.  I truly have more appreciation for this category because the truth is I'm heading there faster than I would like.

I have had this blog now for several years, and I remember when I started it I wanted to fall in the ranks with others that griped about retail.  I had a different story for most every HOUR of the day.  Things that you could never imagine were happening around me and it was so very entertaining.

I went through a conversion from retail to home infusion to LTC to hospital.  The last move was made for me because the LTC I worked on sold to another company and lay-offs were happening.  I had to find a place before it was my turn.  I would probably still be there had it not fallen on hard times running customer service, the IV program and maybe even PIC.  Who knows.  Things change all the time just like in every area of life and you have to take the bull by the horns and work with what you have.

The original question:  Pharmacy residency or not?  If you are graduating from pharmacy, please for the love of God do a residency.  There are too many pharmacists now and you have to differentiate yourself.  If you are not or cannot do one, find a niche.  Find something that doesn't have a glass ceiling.  Pass the BCPS exam after three years of experience.

Does the three year rule of working before you can take the BCPS equal one year of residency then?  Perhaps.  I can see how this is a good rule of thumb of knowledge.

Who would you hire of the three and why?

Read this article.  Seriously a good read from the ACCP.

Tamiflu: Prepared From Tamiflu Capsules

Extemporaneously Prepared

If the commercially prepared oral suspension is not available, the manufacturer provides the following compounding information to prepare a 6 mg/mLsuspension in emergency situations.

1. Place the specified amount of water into a polyethyleneterephthalate (PET) or glass bottle.

2. Carefully separate the capsule body and cap and pour the contents of the required number of 75 mg capsules into the PET or glass bottle.

3. Gently swirl the suspension to ensure adequate wetting of the powder for at least 2 minutes.

4. Slowly add the specified amount of vehicle to the bottle.

5. Close the bottle using a child-resistant cap and shake well for 30 seconds to completely dissolve the active drug.

6. Label “Shake Well Before Use.”

Stable for 35 days refrigerated or 5 days at room temperature. Shake gently prior to use. Do not dispense with dosing device provided with commercially-available product.

Preparation of Oseltamivir 6 mg/mL Suspension

Body Weight	Total Volume per Patient1	# of 75 mg Capsules2	Required Volume of Water	Required Volume of Vehicle2,3	Treatment Dose (wt based)4	Prophylactic Dose (wt based)4
1Entire course of therapy.
2Based on total volume per patient.
3Acceptable vehicles are cherry syrup, Ora-Sweet® SF, or simple syrup.
4Using 6 mg/mL suspension.
≤15 kg	75 mL	6	5 mL	69 mL	5 mL (30 mg) twice daily for 5 days	5 mL (30 mg) once daily for 10 days
16-23 kg	100 mL	8	7 mL	91 mL	7.5 mL (45 mg) twice daily for 5 days	7.5 mL (45 mg) once daily for 10 days
24-40 kg	125 mL	10	8 mL	115 mL	10 mL (60 mg) twice daily for 5 days	10 mL (60 mg) once daily for 10 days
≥41 kg	150 mL	12	10 mL	137 mL	12.5 mL (75 mg) twice daily for 5 days	12.5 mL (75 mg) once daily for 10 days

Related articles

• Tamiflu approved for children 2 weeks and up (vitals.nbcnews.com)
• FDA Approves Tamiflu for Infants (lunaticoutpost.com)
• FDA Approves Tamiflu for Infants (webmd.com)
• Flu Drug Tamiflu OK for Babies Under 1: FDA (news.health.com)
• Flu Drug Tamiflu OK for Babies Under 1: FDA (oddonion.com)
• So You Have the Flu... Now What? (yourvirtualpharmacist.com)

Flu Arrives Early This Year: Just in Time for the Holidays!

Ever seen the flu map?  It is pretty neat.  So is Google's Flu Trends.  Alabama, Louisiana, Mississippi, Tennessee and Texas are seeing the most flu activity, the level of influenza activity in Georgia is picking up, according to the U.S. Centers for Disease Control and Prevention. Flu season typically peaks in January; however this year the flu is making an earlier start thus logically giving the possibility of an earlier peak.  I am hoping my flu shot will keep this nasty virus away!

I love what this doctor says:

“This year’s vaccine appears to be right on target with the circulating virus,” said Dr. William Schaffner, chair of preventive medicine at Vanderbilt University Medical Center in Nashville, Tenn. “Treat it as a holiday gift to yourself and everyone around you. Don’t be a Grinch by spreading the flu.”

The CDC Director says:

“We’re seeing the beginning of the uptick start at least a month before we’d generally see it,” said the CDC director, Dr. Thomas Frieden. “It looks like it’s shaping up to be a bad flu season.”

And last a great article:  12 Flu Myths Debunked

Don't Be Afraid to Fail

All Things Vancomycin

Believe it or not, vancomycin was first isolated in the fifties from an isolate of dirt in the jungles of Borneo by a missionary. It is a naturally occurring antibiotic made by the soil bacterium Actinobacteria. The name vancomycin comes from the word vanquish.  Initially it was used as a sort-of last resort for penicillinase-producing strains of Staphylococcus aureus.  Today, vancomycin is one of the most widely used antibiotics for the treatment of serious gram positive infections involving methicillin-resistant S. aureus (MRSA). Years ago, early use of vancomycin was associated with several different types of toxicities including infusion related effects (Red Man Syndrome), nephrotoxicity (kidney), and possible ototoxicity (damage to ears).  It was determined later that the majority of these adverse effects were due to the early formulations that contained impurities; however, by that time, its use was decreased with the development of other penicillin-type medicines like methicillin, oxacillin, and nafcillin).  Thanks to MRSA, Vancomycin is making a huge comeback, or has been since the early 1980s.

On a side note, Red Man Syndrome is not an allergic reaction.  This can be managed with a histamine blocker or slowing down the infusion.  Can't tell you how many times I have seen this listed as an allergy to vancomycin on someone's profile.

In monitoring Vancomycin, trough serum concentrations are the most accurate method.  Typically draw the trough level prior to the fourth dose (steady-state).  Keep trough levels above at least 10 mg/L to avoid development of resistance.  For a pathogen with an MIC of 1 mg/L, the minimum trough concentration would have to be at least 15 mg/L.  For complicated infections, the optimal trough concentrations are 15-20 mg/L to improve penetration, increase optimal serum concentrations, and improve clinical outcomes.

How to dose?  Dosing vancomycin is a bit of an art, but start at 15-20 mg/kg using actual body weight.  Many hospitals encourage a maximum dose of 2 grams.  Definitely adjust dose in renal dysfunction.

Creatinine Clearance(based on Cockcroft and Gault and not eGRF)	Dose*
>60 ml/min	Uncomplicated Infections: 10-15 mg/kg q12h1  Serious Infections: Consider loading dose of 25mg/kg IV x1, followed by 15-20 mg/kg q8-12h (45-60mg/kg/day divided q12h or q8h)2
40-60 ml/min	10-15 mg/kg q12h-q24h
20-40 ml/min	5-10 mg/kg q24h
10-20 ml/min	5-10 mg/kg q24h-q48h
<10 ml/min	10 - 15 mg/kg IV loading dose x1; redose according to serum levels
Hemodialysis	15-20 mg/kg load, then 500 mg IV post HD only
CVVH	10-15 mg/kg q24h

* round dose to 250mg, 500mg, 750mg, 1g, 1.25g, 1.5g, 1.75g or 2g (maximum: 2gm/dose)

Higher total daily doses of vancomycin have been associated with nephrotoxicity

¹ For patients with uncomplicated infections requiring vancomycin, trough levels of 10-15 mcg/ml are recommended.

² For patients with serious infections due to MRSA (central nervous system infections, endocarditis, ventilator-associated pneumonia, bacteremia or osteomyelitis) , trough levels of 15-20 mcg/ml are recommended.

Vancomycin troughs are not recommended in patients in whom anticipated duration of therapy is short (≤ 3 days)

Trough levels are recommended for routine monitoring (for intermittent hemodialysis, a pre-dialysis level should be drawn). Trough levels should be obtained within 30 minutes before 4^th dose of a new regimen or dosage change.

Once weekly monitoring is reasonable in patients with stable renal function and clinical status. (Data supporting safety or prolonged troughs of 15-20 mcg/ml is limited.)

There is a great app out there I recommend called Vancomycin ClinCalc Full.  The author also has a website called ClinCalc you can check out to see if the dosing matches how your particular program wants you to do it.

I don't earn a dime for that link either, I just enjoy finding quality programs to work more efficiently.

I love Dr. Walter Crittenden, PharmD MD "An Infections Disease Compendium:  A Persiflagers Guide" on the iPad as well.

One of my biggest pet-peeves is when I hear someone say, "Oh I have blown their kidneys!" in regards to one serum creatinine level coming back higher.  Hey, let's wait until 2-3 consecutive high serum creatinine concentrations (increase of 0.5 mg/dL or 150% increase from baseline, whichever is greater) after several days before making such a claim.  Seriously.

And the "Rants and Screeds" of Dr. Crittenden, "Vancomycin is a shitty drug; mostly static, toxic, lousy pharmacokinetics, penetrates poorly into all tissues.  When compared to beta lactams, it is always worse."

Gotta love that!

BCPS 2012 Results: Blonde Pharmacist will repeat!

So the results are rolling in now, and if you are at all finding this post because you are frantic about finding your results, you will know today or early next week.  Mine arrived yesterday and though I am a bit disappointed, I am ready to start studying again as soon as Christmas is over.  In hindsight, since it is 20/20, I can say I am proud of how I did.  I graduated with a Doctor of Pharmacy in 1999.  Things have changed a lot since then, including my personal life.  I now manage two toddlers, a full-time job, and a part-time gig.  (Multi-task much?)  I have dreams of all kinds as far as online things are concerned, want to change the world, and decided to take this BCPS challenge on as a way to propel myself, not only in my current knowledge, but as a great resume builder.  There are many reasons pharmacists take this test. The passing score this year is 122.  The average was 130.  The range was 50-188.  Standard deviation 25.

Domain 1:  Maximum score 120, Average score 77

Domain 2:  Maximum score 50, Average score 33

Domain 3:  Maximum score 30, Average score 20

I missed it by very little.  I am not at all upset and depressed or any of that.  I went into it as a practice because being out of school for 13.5 years is very significant.  New drugs have arrived, new guidelines have changed the scope of practice, and residency trained pharmacists along with newer grads (>3 yrs) are the majority of the test takers.  This last point may be an incorrect assumption because I do remember a couple of ladies I met who "had something to prove to the younger pharmacists."  I truly hope both of them passed because those are the types that will be a lot more disappointed with a fail letter than me.  I have a pharmacist friend that was so upset with her fail that she refused to talk to anyone about it and threw away all the material.  I guess if I went into it thinking I would pass, I would feel that way.

Do I plan to retake?

YES.

That was my plan all along, ask anyone who knows me.  I know that many may have thought my comments of "It was tricky.  I know I didn't pass or if I did 'barely.'" was an attempt to pretend or whatever, but it was the truth.

It was tricky.

Know your guidelines.

Realize that A LOT of studying is required unless you have a very diverse clinical program at your large hospital.  For example, we don't see any trauma, very few TPNs, and other big topics on the test.

And if you have children, especially babies/toddlers... it is VERY tough.  Where is the time?

I should have taken this back when I had a more clinical position at a larger hospital, wasn't married, and certainly had no children absorbing every single free moment.  So if that's your current situation, PLEASE for the love of God take the test.  It will be tougher later.  I am PROOF!

So there.  There's my result (missed it by just a hair)... and had I taken it last year (passing was 111) I would have passed by several points.

Every year is different.

I plan to start studying very soon.  May start listening to the lectures in my family van (HA) starting now since I know.

Nothing hard should be attained easily.

Related articles

• BCPS 2012 | a small review of my thoughts of the test (theblondepharmacist.com)
• Community Pharmacists (michaelgrist.wordpress.com)
• The Perfect Medical Model (theblondepharmacist.com)

Antidepressants and High Blood Pressure

Unfortunately, you may have to try several different antidepressants until you find the one that is right for you and your symptoms.  If you have depression and high blood pressure, you have to find the right med that won't exacerbate blood pressure. A good physician will find out several things.  First, he/she will examine you and your symptoms and take into consideration medications that have worked for others in your family.  Usually someone presenting with blood pressure and depression will have someone else in their family suffering with the same thing.  He/she should ask what other medications you are taking.  You don't want to select a drug that will interact with something you are already on.  For example, if you are taking imitrex for headaches, I wouldn't want to see an SSRI added, or maybe change the imitrex to something else.

A good physician should also ask what other conditions you suffer from, if you are pregnant or breastfeeding, what symptoms you are experiencing, and even what insurance you have or what will be covered.  I know this last one is overlooked, but if a patient can't afford a medicine, what is the point of even seeing a physician if cost isn't taken into consideration DURING the visit.

There are a few antidepressants that are documented to possibly cause an increase in blood pressure.  Bupropion (Wellbutrin, Zyban), venlafaxine (Effexor), and duloxetine (Cymbalta) are a few.  Ironically enough there are some studies out there to show that depression itself can cause a decrease in blood pressure and treating depression an increase.

Keep in mind, these medications are not off the table for treating depression, your physician just may have to adjust your blood pressure medications while you are taking antidepressants.  Close monitoring, adherence to regimen and lifestyle changes can make this situation a lot better.

Related articles

• Coping With Antidepressant Side Effects (everydayhealth.com)
• High Blood Pressure Can Be Caused By Loneliness? (holistichealthliving.wordpress.com)
• Antidepressant risk to thousands of pregnant women (telegraph.co.uk)

5-Hour Energy Drink and Death

My heart raced when I saw this.  No pun intended.  I tend to down one prior to a run.  Maybe something I will reconsider, but I also drink a lot of coffee daily so maybe I have tolerance like an alcoholic to alcohol?

Thirteen deaths have been linked to the consumption of 5-Hour energy drinks according to a report by the Food and Drug Administration.  With the fatalities the energy 'shot' has been also linked to heart attacks, convulsions and in one case a spontaneous abortion according to 90 filings with the FDA released to the New York Times this week.  Question:  Um, yeah, avoid caffeine when you are pregnant, mmm kay?

Add also Monster Energy Drink, which I'm almost positive is the official drink of the retail and hospital pharmacist, to the list with the parents of Anais Fournier suing the company over her death.  Only 14-years-old, the parents allege she only drank two in a 24 hour period before becoming ill.

HAGERSTOWN, Md. -

The U.S. Food and Drug Administration is investigating reports of five deaths that may be associated with Monster Beverage Corp.'s energy drink.

The agency acknowledged the adverse reports Monday, but FDA spokeswoman Shelly Burgess says the reports don't prove that the drinks caused the deaths.

This follows news that the parents of Hagerstown, Md. teen Anais Fournier filed a lawsuit in California on Friday against Monster Beverage Corp. for failing to warn about the product's dangers.

The 14-year-old's family says she went into cardiac arrest last December after drinking two 24-ounce cans of Monster Energy Drink in 24 hours.

An autopsy concluded she died of cardiac arrhythmia due to caffeine toxicity. She had an inherited disorder that can weaken blood vessels.

Monster says it doesn't believe its products caused any deaths.

Your Virtual Pharmacist Guest Post: Coronary Artery Disease

[youtube http://www.youtube.com/watch?v=xd8LgihLouM] You are in a hospital room and overhear the physician say the word (or you think it's a word) "STEMI." What exactly does this mean? Coronary artery disease and it's consequences do not have to be a foreign language.

First of all coronary artery disease is just a fancy term for heart disease. Basically, when the choloesterol is high, plaque is able to be formed and gathers in the heart arteries (or coronary arteries). When this plaque is growing, it can form a clot due to attracting platelets that are gathering to try to heal or fix the plaque. This platelet rich clot grows to the point of stressing the heart whether completely or incompletely.

There are currently three different types of CAD (coronary artery disease) types. The least invasive is UA or unstable angina. Basically angina means heart pain. The second is called NSTEMI or non S-T wave elevation myocardial infarction. The third is called STEMI or S-T wave elevation myocardial infarction.

UA and NSTEMI present the same. Both with chest pain. The difference between the two is that NSTEMI has coronary markers or troponin involved. UA does not. NSTEMI is a clot that is not complete. STEMI, on the other hand, is a complete clot and more of an emergency because cell death is happening in the heart muscle. With no blood flow down a coronary artery, the heart muscle is dying. When the heart muscle cells begin to die due to lack of oxygen and blood, the heart cannot function properly and will go into erratic rhythms. Most of the time, this is what causes death.

The difference between NSTEMI and STEMI is the S-T elevation in the heart waves. S-T elevation signifies cardiac cell death and is a more serious event.

The reason why your doctor will always give you aspirin is due to aspirin's anti-platelet effects. Aspirin is a wonderful drug in that it targets that platelet rich clot that is forming in your coronary arteries and helps to prevent a heart attack. It is also the FIRST thing that you should take if you feel the symptoms of a heart attack coming on... aspirin 81 mg. Well, that and if you have a nitroglycerin sublingual tablet and get to the emergency room fast!

The goal is to prevent these events from happening in the first place. The statins are a class of drugs that help to reduce cholesterol, specifically LDL in the bloodstream to prevent these clots from forming (Lipitor, Pravachol, Zocor, etc... ). Diet and exercise are the best to try first.

I hoped this helped to clear up some of the more complex terms of coronary artery disease.