Conversations with providers that made you think "WTF?"

[Dred Pirate]

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Obviously all professions have their idiots (ours is definitely not exempt from it) - but have you ever had an interaction/question from a providers (usually an NP vs a physician) and thought - how the hell don't you know that?

Had one today -
NP decreases a patients levothyroxine, I look up their TSH- it was like 14 - I call her, "why did you decrease their levothyroxine?"

She said "Their TSH is high"

me "I see that - don't you think we should increase their dose instead?"

Why would I do that? It will make it go even higher

ah? you're kidding right?

2 minutes later and sending her a link to how to dose meds, she realizes she was wrong.

SMH -

 

[RxPreceptor]

😧
I think many of us are just baffled daily on a daily basis how terrible providers are with simple stuff like units, conversions

had a recent hilarious interaction with a customer who thought his thermometer was broken…it was in Celsius (had to explain it to him a couple times before he understood). Seriously, I think the imperial system makes people dumb and find it ironic that the US still uses it (UK not using it)

 

[DagS132]

...Seriously, I think the imperial system makes people dumb and find it ironic that the US still uses it (UK not using it)

lmao, you wish you could blame it on the imperial system

 

[Dred Pirate]

😧
I think many of us are just baffled daily on a daily basis how terrible providers are with simple stuff like units, conversions

had a recent hilarious interaction with a customer who thought his thermometer was broken…it was in Celsius (had to explain it to him a couple times before he understood). Seriously, I think the imperial system makes people dumb and find it ironic that the US still uses it (UK not using it)

I always joke when I see a temperature in celsius - "what is that in 'merican?"

 

[Dred Pirate]

another one- I had a cardiology NP admit to me she didn't know the different in lovenox treatment dose vs prophy dose - like I get if she asks my abx recommendation, or if was a NP in endocrine or something, but like - cardiology -if anything you should know that one.

 

[Xenophylia]

If I had a nickel for every physician (and nurse) that I've had to argue with to make them realize morphine sulf 20mg/ml and 100mg/5ml are the same thing I could retire many times over.

 

[RXDOC1986]

I don't even have to get into clinical / medical issues to say WTF!
Large, regional, teaching hospital. We have a direct messaging function, allows us direct/immediate access to prescribers. Never, ever pose a question that has multiple possible responses. Anything you ask has to be yes or no response. For example, Dr. Feelgood, should we begin with a 2 GM loading dose or continue with prior regiment? -And you get a response of "yes", or "okay" from MD. WTF? yes to what?
Or asking: patient uses non-formulary horse tranq., can we auto-sub or wait for home supply? and again, you get "sure", go ahead - WITH WHAT?
This is an endless source of amusement for us.
I wish I was joking about this matter!

 

[Splenda88]

If I had a nickel for every physician (and nurse) that I've had to argue with to make them realize morphine sulf 20mg/ml and 100mg/5ml are the same thing I could retire many times over.

Strange. I attended a bottom 20 MD school, and my classmates were quite intelligent.

 

[Xenophylia]

I wish I was making it up, trust me...

 

[RXDOC1986]

Strange. I attended a bottom 20 MD school, and my classmates were quit intelligent.

Yes, without a doubt, our best and brightest young people go to Medical Schools. Having dealt with attendings all the way down to med students, intelligence and common sense are often mutually exclusive! I have never questioned an M.D.s intelligence, but mostly their listening ability, comprehension, and common sense.

 

[mentos]

I had a provider order OTC magnesium citrate soln (for constipation/bowel prep) to be given IV. He was trying to order IV magnesium sulfate 2g and didn't know the difference.

Another provider ordered 1mL of furosemide 10mg/mL oral soln to be given IV. I told her to change it to the IV vial. She didn't know which size to select - 2mL, 4mL or 10mL. I asked what is the dose and she said 40mg. So I said 4mL vial because there's 10mg/mL. She orders the 4mL vial but puts 10mg as the dose. I said the dose has to be 40mg. She said "but it says 4mL vial, 10mg/mL so that's 10". It's like she didn't know what concentration was.

 

[Dred Pirate]

I had a provider order OTC magnesium citrate soln (for constipation/bowel prep) to be given IV. He was trying to order IV magnesium sulfate 2g and didn't know the difference.

Another provider ordered 1mL of furosemide 10mg/mL oral soln to be given IV. I told her to change it to the IV vial. She didn't know which size to select - 2mL, 4mL or 10mL. I asked what is the dose and she said 40mg. So I said 4mL vial because there's 10mg/mL. She orders the 4mL vial but puts 10mg as the dose. I said the dose has to be 40mg. She said "but it says 4mL vial, 10mg/mL so that's 10". It's like she didn't know what concentration was.

this the issue I have with CPOE - these types of issues never would come up in a written chart - a physician should not have to order a specific vial size - that is just stupid. Just like when I had a doctor order dopamine 5 mcg IV - like just a one time order - I know that isn't what the meant- they wanted it to run at 5 mcg/kg/min- they don't care what fluid it is in (most of the time) - they just want the standard that is in the pyxis - that isn't on them to know - that is our job.

All CPOE did is replace one time of errors with another.

 

[panicatthepharmacy]

I always joke when I see a temperature in celsius - "what is that in 'merican?"

Handy little (very) rough Celsius to conversion I heard as a kid (we got mostly Canadian TV and radio stations):

"30 is hot,
20 is nice;
10 is cool, and
0 is ice."

or

"0 is cold,
10 is not;
20 is warm, and
30 is hot."

 

[Sakonji]

I don't mind dealing with "dumb" providers. If they know everything then there will be fewer of us around. In fact I am happy to do it, and pass no judgement. I am sure there are millions aspects of their jobs that I am completely dumb about.

What I don't agree with is how long it takes to get any issue resolved, at least in the retail setting. Just trying to find out why someone is given eliquis QD takes days and weeks and millions of voicemails

 

[Sparda29]

Nurse calls me asking if it's okay to low-port/ y-site clinimix with intralipids. Trissel's says no data so I tell the nurse to just open another line. Nursing supervisor calls down demanding why I told them to open another line. Told the nursing supervisor if I don't see the word compatible I'm not gonna say it's okay. Told him if they've done it before and it's worked that's on them but don't say pharmacy said it's okay.

 

[Dred Pirate]

Nurse calls me asking if it's okay to low-port/ y-site clinimix with intralipids. Trissel's says no data so I tell the nurse to just open another line. Nursing supervisor calls down demanding why I told them to open another line. Told the nursing supervisor if I don't see the word compatible I'm not gonna say it's okay. Told him if they've done it before and it's worked that's on them but don't say pharmacy said it's okay.

I am gonna have to call you out on this one. If I heard a pharmacist say this I would say “WTF?” Places literally make 3 in 1 TPN where we literally mix them together. A little deductive reasoning is needed here .

 

[GrandTheftAutumn]

I wonder what are some of the WTF responses pharmacists gave to other healthcare professionals.
Judging by the unacceptably low NAPLEX pass rates nowadays, I'm sure our colleagues have given responses/recommendations that were better off not given.

 

[sfachine]

I wonder what are some of the WTF responses pharmacists gave to other healthcare professionals.
Judging by the unacceptably low NAPLEX pass rates nowadays, I'm sure our colleagues have given responses/recommendations that were better off not given.

Everyone on this thread is perfect.

 

[CetiAlphaFive]

Obviously all professions have their idiots (ours is definitely not exempt from it) - but have you ever had an interaction/question from a providers (usually an NP vs a physician) and thought - how the hell don't you know that?

Had one today -
NP decreases a patients levothyroxine, I look up their TSH- it was like 14 - I call her, "why did you decrease their levothyroxine?"

She said "Their TSH is high"

me "I see that - don't you think we should increase their dose instead?"

Why would I do that? It will make it go even higher

ah? you're kidding right?

2 minutes later and sending her a link to how to dose meds, she realizes she was wrong.

SMH -

My favorite is dealing with provider offices who act like they've never seen a computer before when you ask them to include text or other compliance stuff in a prescription.

BUT, when it's time for them to put "tell patient they need an office visits for more refills" they have no issue

 

[CetiAlphaFive]

I am gonna have to call you out on this one. If I heard a pharmacist say this I would say “WTF?” Places literally make 3 in 1 TPN where we literally mix them together. A little deductive reasoning is needed here .

There's probably a thread somewhere where people are
Trading Sparda stories without knowing it

 

[Dred Pirate]

I wonder what are some of the WTF responses pharmacists gave to other healthcare professionals.
Judging by the unacceptably low NAPLEX pass rates nowadays, I'm sure our colleagues have given responses/recommendations that were better off not given.

Yup. I will throw one out there.

Rph called the cardiology NP saying we need to stop the tikosyn because they have completed their three day load.

 

[Dred Pirate]

I wonder what are some of the WTF responses pharmacists gave to other healthcare professionals.
Judging by the unacceptably low NAPLEX pass rates nowadays, I'm sure our colleagues have given responses/recommendations that were better off not given.

another one -
a rph saying that can't approve haldol without an EKG in a patient who is currently acutely psychotic and violent and requiring 5 police officers to hold them down.

I will even throw myself under the proverbial bus - I called a doc to question the use of nipride instead of nicardipine- I didn't realize he was literally coding the pt at the time - his response "I will worry about that if he is still alive in 15 minutes"

 

[mustang sally]

I had a hospitalist tell me she wanted a PCA for a patient. I asked her if she wanted a CBR and she asked what’s a CBR (too acronymy maybe??).

Another Dr got into an argument with me about using PO vanco for cellulitis. She clearly didn’t believe me when I told her it doesn’t get systemically absorbed.

To be fair though, nobody can know everything and I definitely know I’m not perfect.

 

[Xenophylia]

A lot of the clueless (typically newer grad) RPhs I have encountered seem to like to keep a low profile. I think they'd rather remain silent than make a bogus recommendation which causes LOLs. Maybe that's a strategy the newer schools are teaching?

 

[Xenophylia]

I made another RPh cry once when I over them telling a patient to take their steroid inhaler BEFORE their bronchodilator. I asked them to explain their logic to me on that recommendation and they couldn't and just fell apart. It's one thing to keep quiet, but to openly give misinformation bugs the crap out of me...

 

[GrandTheftAutumn]

A lot of the clueless (typically newer grad) RPhs I have encountered seem to like to keep a low profile. I think they'd rather remain silent than make a bogus recommendation which causes LOLs. Maybe that's a strategy the newer schools are teaching?

That's rather shocking, considering their "doctor" egos are almost as big as their student loans yet they manage to keep their mouths shut.
I guess they're being taught something at least. Just not anything that leads to higher pass rates.

 

[Xenophylia]

Kind of like they want to "Talk the talk" but not "Walk the walk" that being a "doctor" implies. Anyone surprised? Empty vessels make the loudest sounds......

 

[Xenophylia]

"To be fair though, nobody can know everything and I definitely know I’m not perfect."

No one is perfect. But it's having someone arguing against logic or plain fact just because they can't accept the reality that they are wrong (usually as a function of job title or degree and it's resulting effect on ego) that is the issue.

 

[Dred Pirate]

I had a hospitalist tell me she wanted a PCA for a patient. I asked her if she wanted a CBR and she asked what’s a CBR (too acronymy maybe??).

Another Dr got into an argument with me about using PO vanco for cellulitis. She clearly didn’t believe me when I told her it doesn’t get systemically absorbed.

To be fair though, nobody can know everything and I definitely know I’m not perfect.

I had to think a bit to figure out CBR

 

[Idk17]

Insisting somebody should be on both Eliquis and Lovenox.

Couldn't figure out why anti Xa is still high after going from a heparin drip to Eliquis; multiple docs and lab were involved.

 

[Dred Pirate]

Insisting somebody should be on both Eliquis and Lovenox.

Couldn't figure out why anti Xa is still high after going from a heparin drip to Eliquis; multiple docs and lab were involved.

reminds me of this story- and this is a long time surgical PA - who I have a lot of respect for.
Pt is on Xarelto for Afib, comes in for knee replacement. Is put on eliquis. Rph calls them thinking this is an easy one.
PA "I know - they need to be on both"
RPh "huh? like, no that is double"
PA "Xarelto is for Afib, eliquis is for DVT prophy"
Rph "that isn't how it works, like one is enough"
PA "I know you have the best intentions, but no, I am not going to dc one of them"

Rph verifies both (why???) Rph that evening calls oncall service to get eliquis stopped.

 

[CetiAlphaFive]

I wonder what are some of the WTF responses pharmacists gave to other healthcare professionals.
Judging by the unacceptably low NAPLEX pass rates nowadays, I'm sure our colleagues have given responses/recommendations that were better off not given.

During my p4 rotations i got stuck with a boomer that only got up to counsel patients when it was an attractive, young female pt.

He would literally step in front of me, hahaha.

Anyway, once i was beginning counseling on a combo HIV drug when he butted in. He stared at the bottle quizzically and then confidently began counseling "a new combo cholesterol medication.".

He warned about grapefruit juice, myalgia, and told them about LDL hahaha.

The patient and i both kept glancing back and forth at each other with wide eyes.

 

[mustang sally]

I had to think a bit to figure out CBR

It must just be me then.

 

[RxPreceptor]

reminds me of this story- and this is a long time surgical PA - who I have a lot of respect for.
Pt is on Xarelto for Afib, comes in for knee replacement. Is put on eliquis. Rph calls them thinking this is an easy one.
PA "I know - they need to be on both"
RPh "huh? like, no that is double"
PA "Xarelto is for Afib, eliquis is for DVT prophy"
Rph "that isn't how it works, like one is enough"
PA "I know you have the best intentions, but no, I am not going to dc one of them"

Rph verifies both (why???) Rph that evening calls oncall service to get eliquis stopped.

This type is another one we encounter a ton…things being ok despite overlapping mechanisms of action because of different indications. Thinking about things purely by indication is the best way to confuse everyone by oversimplification

 

[BC_89]

Story #1

- 60 year old female admitted to ICU for suspected sepsis, unknown origin {~70 kg, unstable renal function, elevated WBCs}
- AM rounds: Intensivist would like pharmacy to put in for zosyn + vancomycin (he's a contractor covering for the week)
- As a habit, I like to insist on the providers to place the consult for pharmacy and I'll keep an eye on it (I'm covering 3rd floor ICU)

For whatever reason, he doesn't want a consult since he likes to "watch his own patients" and wishes for 2g every 8 hours so that we get a faster trough level...I suggested starting a loading dose then place a consult, of which they were irritated (among other things) and of course, wanted the actual critical care pharmacist...

Pharmacy ended up getting the consult.

Story #2

Patient admitted to the floor
- certain meds placed with non-critical home meds ordered
- later that day, entresto is placed with lisinopril discontinued
- I adjust the timing for a "wash-out" period

Hospital Resident reaches out asking why I am pushing out the entresto for a couple of days. I explain the 36-hour washout period with the ACEI vs ARB component of entresto. Resident states "Yea I know, but lisinopril and valsartan are the same drug-class."

Confidently, I myself have given plenty of WTF responses that plenty of nurses and providers talk about behind closed doors over the span of my PGY-1 experience...

 

[VA Hopeful Dr]

Story #1

- 60 year old female admitted to ICU for suspected sepsis, unknown origin {~70 kg, unstable renal function, elevated WBCs}
- AM rounds: Intensivist would like pharmacy to put in for zosyn + vancomycin (he's a contractor covering for the week)
- As a habit, I like to insist on the providers to place the consult for pharmacy and I'll keep an eye on it (I'm covering 3rd floor ICU)

For whatever reason, he doesn't want a consult since he likes to "watch his own patients" and wishes for 2g every 8 hours so that we get a faster trough level...I suggested starting a loading dose then place a consult, of which they were irritated (among other things) and of course, wanted the actual critical care pharmacist...

Pharmacy ended up getting the consult.

Story #2

Patient admitted to the floor
- certain meds placed with non-critical home meds ordered
- later that day (central pharmacy), entresto shows up for verification with lisinopril discontinued
- I adjust the timing for a "wash-out" period (admin to pharmacy to adjust per protocol/timing interval)

Hospital Resident reaches out asking why pharmacy is pushing out the entresto for a couple of days. I explain the 36-hour washout period with the ACEI vs ARB component of entresto. Resident states "Yea I know, but lisinopril and valsartan are the same drug-class."

Confidently, I myself have given plenty of WTF responses that plenty of nurses and providers talk about behind closed doors over the span of my PGY-1 experience...

Its been a long time since I've done inpatient medicine, but every time I would order a medication and it said "pharmacy to dose" I would just about set the mouse on fire clicking that option.

 

[Dred Pirate]

Story #1

- 60 year old female admitted to ICU for suspected sepsis, unknown origin {~70 kg, unstable renal function, elevated WBCs}
- AM rounds: Intensivist would like pharmacy to put in for zosyn + vancomycin (he's a contractor covering for the week)
- As a habit, I like to insist on the providers to place the consult for pharmacy and I'll keep an eye on it (I'm covering 3rd floor ICU)

For whatever reason, he doesn't want a consult since he likes to "watch his own patients" and wishes for 2g every 8 hours so that we get a faster trough level...I suggested starting a loading dose then place a consult, of which they were irritated (among other things) and of course, wanted the actual critical care pharmacist...

Pharmacy ended up getting the consult.

nce...

I am so glad I work in a place were we don't even have to ask for permission to change any doses for any antibiotic.

Plus the zosyn + vanc = AKI this is starting to be debunked- but if already in AKI I would still avoid,

 

[Sakonji]

I am so glad I work in a place were we don't even have to ask for permission to change any doses for any antibiotic.

Plus the zosyn + vanc = AKI this is starting to be debunked- but if already in AKI I would still avoid,

I mean, what is a staff pharmacist expected to do if the provider insists on their WTF combo, keep fighting or just document and move on?

 

[Dred Pirate]

I mean, what is a staff pharmacist expected to do if the provider insists on their WTF combo, keep fighting or just document and move on?

I guess it depends on the combo. Vanc zosyn I don’t have an issue any more. Eliquis and xarelro? Nope. Not gonna verify. I personally have never ended up in a situation I wasn’t able to come to common ground on.

 

[BC_89]

light-hearted, but definitely relatable when I think of hospital phone conversations with nurses/providers and WTF moments:

 

[Dred Pirate]

light-hearted, but definitely relatable when I think of hospital phone conversations with nurses/providers and WTF moments:

I love that guy