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Discussion in 'Pharmacy' started by starsweet, May 10, 2008.
Just watch the video...
What an idiot.
Ehh... she was lucky that it didn't happen in McDonald's, Lowe's, Office Depot, etc. They don't sell glucose meters.
Where was the pharmacist?
We just had a patient faint recently, and the pharmacist assisted in the entire process. It looks like the nurse and the cop took the situation into their own hands instead of contacting the pharmacist.
Orange juice??? I thought you're not allowed to give them OJ because that would send them from one extreme to another.
Well I think they (Fox) were trying to paint Walgreens as the big evil corporation, so I'm sure the pharmacist helped but they left that part out to make Walgreens look worse.
it looks like the store manager was a big issue - not a pharmacist.
I hear from people who work at Wags that there is a lot of strife between the store managers and pharmacists. The managers are resentful of how much the pharmacists make.
no...at least not at my store...the store managers and pharmacy staff at my store go out and party every so often
Eh.. . . to be fair, as much as it is a courtesy to assist a lady in medical danger, the only thing a manager or the pharmacist should do is call 911. I think the manager was right in giving the orange juice and sugar tablets for free, but not the glucose meter.
In the tri-state area, an ambulance's average response time is usually less than 3 minutes. That is enough time in my opinion for a person to get help. Really, I can understand the sugar tablets and orange juice (which walgreen did not charge). . . but what is the point of the sheriff grabing a glucose meter? What right does she have? I would hope as pharmacists, we WILL do the best to assist our patients. . . but due to liability reasons, know when to call 911 and take it as if the patient was on the streets. This was how I was taught. . . and it can be an urban New Yorker thing.
In terms of the medical condition, I did a rotation in the ER and DKA, HHS, etc are one of the main reason why people came in. Even if a patient is hypoglycemic, a challenge with D5W and fluids will do the trick. Brain death is really rare. If I was in an ambulatory pharmacy, most I would do is provide glucose pills and call 911. The paramedics will take care of the rest.
Maybe some of the senior pharmacists can weigh in?
Depends how much you give. I just attended a lecture on this topic and 4 ounces of orange juice is considered okay.
There is nothing at that website when I click. But I am assuming it was an incident of hypoglycemia? The rule of 15 usually applies. Give an equivalent of 15 grams of sugar and wait 15 minutes. The first thing to do is CONFIRM. After 15 minutes, you check again to make sure the patient is stabilized. Check the blood sugar to make sure the patient is hypoglycemic- since you don't want to skyrocket their bloodsugar, otherwise. The way to confirm is by using a blood glucose meter.
If you think your blood glucose is too low, use a blood glucose meter to check your level. If it is 70 mg/dL or below, have one of these "quick fix" foods right away to raise your blood glucose:
2 or 3 glucose tablets
1/2 cup (4 ounces) of any fruit juice
1/2 cup (4 ounces) of a regular (not diet) soft drink
1 cup (8 ounces) of milk
5 or 6 pieces of hard candy
1 or 2 teaspoons of sugar or honey
Again, I didn't see the case since the link doesn't work, but if the Rph did not wish to take a blood glucose meter off the shelf for the patient's use, then that's just bad form. An emergency's an emergency, and you could justify later. It's part of a common hypoglycemia treatment protocol.
The sheriff had a right to do what's right in an emergency. The same thing that allows them to kick in the door of an apartment they may raid, etc. They could reimburse afterwards, which they usually do. Everyone's so darn stingy these days... This is a very stupid manager, it sounds like. I'm sure corporate would have been very good about replacing one due to the nature of the emergency. It's a drop in the bucket versus a public relations nightmare. I'd go with the former...
Did they remove the patient from the store or something? Sounds like an attempt to limit liability, or at least to make it where they don't have to possibly pay for the EMS transit. I never understood citing liability as a rationale that could let a patient suffer.
Common sense shows that a jury's going to sympathize more with the patient who was kicked to the curb, than the company with all the tools to help, which stood by and did nothing; on the flip-side, a jury will empathize a lot more with the pharmacist who tried to help. I think there's a weird sense of the priorities these days.
Maybe your right about only call 911, but is someone grabs a blanket or a bandage or glucose meter or anything in the time of a medical emergency to help another person, how can you charge them for that? That is ridiculous. If the manager just took the box and put it wherever you put empty boxes that were stolen there would be no issue, the manager would not get in trouble, and if anyone questioned that, I would find it hard to believe that someone would think that he should have tried to get the money for the glucose meter. Except for you apparently.
Seriously though, what would you do in certain situations?
There are a few I can think of. Would you give someone an albuterol inhaler if they asked for it and were in distress, would you give someone an epipen that was stung by a bee and having a severe reaction, would you give someone a NTG if they were complaining of severe chest pains and asked for it?
Yep, it's a drop in the bucket versus a public relations nightmare. I'd go with the former... This manager should have notified his corporate offices (district, etc) of the emergent nature of the incident, and that the police needed this to be done. They'd surely replace it on the shelves. I know I would. I would have not only replaced it on the shelves, but written letters commending the actions of the workers, and customers (which finally came at the very end). They could have had these customers for life. Instead, folks are even too disgusted to even get a deserved refund from them. Nothing against Walgreens, they had no idea how ******ed this manager was until he was placed in an emergency environment and functioned like a repo-man.
People (in this case Store Managers) are just too dumb where they snatch terrible PR from the jaws of commendation and good publicity. What better publicity (from a news story) than for elderly patients to know that if something happened to them in the store, that they wouldn't be on their own, and that store managers understand the importance of getting help. I think that's the 'caring' part that always seems to get advertised. Or maybe that was just those CVS commercials... There should be a disclaimer on the bottom: but you're on your own if you go into a hypoglycemic coma. $17 blood glucose meters are just way too valuable. Taxes apply.
You need the glucometer to verify the patient is in fact hypoglycemic and not unconscious for some other reason, so you don't end up administering sugar to someone in cardiac arrest, say.
I was also wondering where the pharmacist was. When I worked full-time in retail, any medical emergency would involve the pharmacist (whether or not I could do bugger-all). Maybe the pharmacist would have a bottle of powdered glucose behind the counter, and then you pick up the unconscious person's tongue and sprinkle the glucose, where it's absorbed SL. Preferable to trying to pour fruit juice into someone at a high risk of aspiration. Alternately, maybe the pharmacist had some glucagon sitting around.
At my current workplace, a jail, I've weaned the nurses off orange juice for the hypoglycemics, bringing in glucose tablets instead. It's true that fruit juices don't supply a consistent amount of sucrose and you tend to push the blood sugar sky-high. Also, if your diabetic is on acarbose (do you have that in the US?), you have to administer glucose for hypoglycemia, as the drug prevents sucrose from being utilized.
1) No. Over-use of short-acting B-agonists results in poorer outcomes, and lots of folks mis-use the albuterol. I've seen people fake asthma attacks because they want a refill on their Ventolin without waiting for me to call their dr, or they want to use the inhaler boot as a crack pipe (big issue where I live).
2) Yes, but call 911.
3) Same as #2.
Good point, though. How far do you take it? What if someone comes in and their blood pressure is sky high; do you give them a 10 mg ramipril? And if you don't and they have a stroke, are you liable?
We could use some more guidance in properly dealing with the people who use their local pharmacy as an ED.
It's easy to tell the difference between a faked asthma attack and one that isn't. That's like looking at everyone who has an Rx for a controlled substance as a junkie. There was a pharmacist who overly-scrutinized every Rx for a controlled substance that was ever filled at his store, and was fired by his company. He cited vigilance standards, and was still released, because the courts found that it shouldn't be an impediment to providing patient care. There's going to be memorable exceptions to every rule. I don't see how the #1 is all that different from #2 or #3. (except that it happened to have a corresponding crack-pipe story, a negative experience indeed, which I never even knew was even a possibility. lol).
It all depends on the workplace, I guess. Have to take special populations into account. If you're at a jail (which you said in your post), maybe they actually ARE Junkies with innovative uses for prescription drug delivery systems!!
OK, folks lets all take a deep breath. There are several issues here.
Issue One: Only a stone cold 100% moron would have attempted to collect the $17.99 from the good Samaritans. Any chain pharmacy could either eat the loss or call the company and get a replacement.
Issue Two: Good Samaritan Laws do not protect health professionals who should know better. Unless the patient informs you they are diabetic and asks for sugar, (I have done this many times over the last 25 years) you are acting as a physician and diagnosing and treating an emergent situation and your liability is great.
Issue Three: This story does not add up. How did the nurse get an unconscious woman to swallow enough OJ to raise her blood sugar? Maybe she wasn't unconscious. Then she didn't follow the rule of 15's. The correct thing to do was administer the OJ or glucose tablets and then wait for the paramedics to arrive. The response time would be less than 15 minutes.
Just remember to look at the story critically and remember human beings do silly things in emergencies....
First off, the reporter in the video is a weenie and an overactor. Sad how devolved American news has become.
The class I just took we were told to always give them the sugar if we don't know which way their blood sugar is running. Not giving them sugar when they are low can result in brain damage/death, and given the woman was lapsing in and out of consciousness I'd definitely have done what the nurses did. Giving them more sugar when they are high isn't nearly as bad, especially considering paramedics should arrive in minutes to correct the situation either way. But opening up a glucometer to test blood sugar? Why? The paramedics will be there shortly and they'll just test the patient before doing anything anyway.
Old Timer, in the video the nurse states that she rubbed sugar in the woman's mouth, then when the woman became semi-conscious they gave her the OJ.
edit: and the store manager was a freakin moron. He could have called up the manufacturer and told them the story and how their device possibly saved a woman's life. They could have made it into a commercial, or offered the woman a year's supply of test strips, and had the local news station do a happy story about the situation. And the fact that corporate stood up for the douche, that's just terrible.
I agree with that last statement. The patient probably had a depressed level of consciousness, not fully unconscious. You're not supposed to give anything by mouth to an unconscious person...
The coma cocktail: narcan and D50. You'll do more damage by letting someone remain hypoglycemic than you will adding to hyperglycemia. It was quick thinking and it wouldn't have been irresponsible not to test her either.
I personally don't think it was necessary to test her blood glucose but it didn't really hurt things. Again, stupid store manager.
I didnt mean to sound meaner than my post say, but I am just trying to play devil advocate here. Most of the time, the media overhype things.
I agree with you. . . as an intern, I had an asthmatic patient come in claiming he needed an albuterol inhaler and even willing to pay money for it. (He lacked the hunchback signs etc). However my pharmacist kindly told him no and told me the only thing I should ever do if a person collapse is call 911. It doesnt matter if the person has an allergic reaction or in this case altered mental status or being unconscienous. I guess that was what I was taught as an intern and still believe today.
I agree with oldtimer. .. we are not physcians and neither is the nurse. If help wasnt readily available (stranded island), I would have done all of the above. However this is Bayonne, NJ. The ambulance with better resouces to handle this is probably right around the corner.
Nurse is a generic term. For all we know she may be a trauma nurse, nurse practitioner, or another specialty that is perfectly capable of handling that sort of situation. On the other hand she could have been a LPN or a nursing assistant.
Good samaritan laws are pretty darn clear. So long as you do what a reasonable person with the same level of training would do, you're fine. You don't have to be a physician to diagnose and treat someone.
One of the nurses I work with arrived at church one Sunday to find a fellow parishioner had collapsed. She was diabetic, and people were pouring orange juice all over her, but she was unconscious, and they were accomplishing nothing but soaking her clothing. So my coworker got a little packet of sugar (don't remember from where) and put it under her tongue. She revived soon after from SL absorption of the sucrose.
What didn't make sense to me was that a nurse wouldn't know better than to administer oral liquids to an unconscious person, who would surely do nothing more than aspirate.
Grabbing the glucometer didn't seem so nutty. Maybe the woman was wearing a Medic-Alert bracelet stating that she was diabetic.
Re: Ventolin inhalers: I will NOT give them out. I have to say, in all the years, and with all the abuse I've taken over not giving them out, I've never seen anybody in genuine respiratory distress.
I mean, if you can get in your car and drive to your pharmacy even though you "can't hardly breathe," surely you can drive to your ED. And if you can scream obscenities at the pharmacist at the top of your lungs, you're not in respiratory distress.
Wow, has anyone actually watched the video?
People actually do that?
playing the devil's advocate here...was wondering if anyone knows of any pharmacists or if they themselves would dispense a prescription med (non-CII) without a prescription if they or their own immediately family members experienced a life-threatening emergency (provided the pharmacist knows the family member victim has no contraindications based on judgment)--this is all in addition to calling 911, of course. I mean, would you let your own family member die? And if this does happen (dispensing the med w/o the Rx), would you later go back and contact the family physician (not only to let the family MD know everything ab his own patient) but also to get a prescription for the med that was dispensed w/o the original Rx)?
say this was your husband, wife, daughter, son, firstborn, grandchild, grandma, etc...
Folks do what they need to do. It's obvious out of the bounds of the profession, but I don't think it's out of bounds of possible actions people could take. If it works, more power to them.
If someone is having a severe anaphylactic reaction and they need to be given an epipen, I'm going to give them the epipen. If someone was seizing I would give them a diazepam (or Diastat ) If someones life is at stake, then I'm going to do what has to be done.
I respect you Rxwildcat, but for somebody graduating in year 2010, would you know how an anaphylactic reaction looks like? How can you be clear without knowing the differentials? Would you really know if somebody is actively seizing? I agree that both drugs are safe and I would probably do the same with the epipen, but would not give out the diazepam.
Gaba, If it was my family, I would not hesitate a moment as long as I deem my training is proficient and I know they need it. Of course, for the majority of cases, and I emphasize majority, the situation will allow a few minutes. . . and sometimes waiting is the best thing to do. Then again, each sitaution is unique. Remember, the pharmacy isnt an ICU and really. . . I cant think of any situation or condition where things are necessary asap and cannot wait for the ambulance. Maybe you guys can give me some conditions (as a learning experience for me) where we might have to give drugs out stat in an ambulatory setting because waiting for an ambulance will put that patient at a significant risk.
At the end of the day - we are all about patient care... If something is needed - damn the costs...
Recently - the Oregon Board of Pharmacy came to talk with us about law enforcement (the BOP here has enforcement powers/officers to do so). They told us that they (BOP) will always side with what is best for the patient. If you break a law, or operate outside your specific duties (as dictated by mandates) to assist a patient - then the BOP will support you and act accordingly.
I do believe it is a double edged sword however...
I actually used anaphylaxis and seizures as examples because I figured they would be immediately obvious. When I said seizing, I meant tonic-clonic. Why wouldn't you give the diazepam, because its controlled? What if the pt had an existing Rx for diazepam, then would you administer the drug and then fill the Rx after? Just playing devil's advocate
The BOP has the same power here. Although they have never directly said anything like that directly to us, I'm sure they would use their judgment and side with caring for the pt. I know a few members (and past members) of the BOP and they are all very reasonable people. I'm glad someone shares my view of things
I wouldnt give diazepam because the guy can wait. The guy isnt in danger of serious rhabdo or anything in the few minutes it take for an ambulance to come. The only thing that I would do as any other people out there would do is to make sure he doesnt fall or hit something. Even if a patient had an exisiting diazepam, I still would not give it. Remember, we are pharmacists who (dispense drugs) and not physcians (who manage conditions). There is nothing for us to gain by giving the diazepam (if the guy can swallow it to begin with), and only a whole load of possible liabilities. For all we know, the guy can just be having a really bad anxiety attack.
A tonic-clonic anxiety attack? What if he aspirated while seizing and died? Who can garauntee that an ambulance is always a few minutes away? Personally I feel if I knew my intervention would prevent serious harm to the patient, I would do it. Also, pharmacist do manage certain disease states.
When I was in undergrad, there was a student who didn't want her professors, or anyone for that matter, to call for an ambulance when she was having a seizure. She had taken so many rides to the hospital for seizures, that her insurance company would not cover any more ambulance bills. This is an unusual case, but it's something to think about.
Not every seizure requires a ride to the ER. Duration, severity, level of consciousness matter.
Ambulance rides are expensive. I was in a car accident a couple of years ago, and the ride alone was $550. I was semi-conscious so I needed to go, but I don't equate ambulance rides with a taxi like a lot of people do.
you don't think having a seizure is serious? being a healthcare professional and witnessing someone suffer in an episode (be it cardiac, brain, etc) is doing just as much harm--do you remember the oath you took when you got your white coat? "do not harm..."
Um, what year are you in? diastat (active ingredient = diazepam) is given rectally, so no swallowing issues: http://www.diastat.com/14-Pharmacists/index.html
that is true; the rule is you don't need to call 911 if the pt has had sz before; of course, if you can see that this one is more serious, then you should call.
From what I learned in class, you should wait for 5 minutes before calling 911, but if the patient doesn't get out of it after 5 minutes, then the patient doesn't have much time left to waste. It really is a tricky situation, and I just hope I never have to witness that. I'm just gonna have to mentally train myself now not to get freaked out and forget what I'm supposed to do at that moment.
(My last year finishing up rotations- I am graduating soon.). I have never heard of diastat, but found it interesting. (Anybody else who is a P3 or P4 heard of it from class? or is it just my school. . . ). Thanks for the information and link gaba.
I still believe that in a seizure, you can wait. . ., and going back to the original post; that can wait too - (in the tri state area). I would give the Diastat if it was in the patient's profile or if he has a prescription for it. Other than that, I say the paramedics can handle it when they come. Of course though, I am biased. .. and I was taught by everybody that I worked with not to do anything.
Legally, is that what we are suppose to do? It seems that is what you are telling me, and maybe things are done differently elsewhere (I am open minded and very interested on what you will do with a variety of situations including the video above). Thanks a lot. Concering the video, do you really believe (and fox is really biased and one sided) that the video is overhyped. Do you really believe that it a diabetic coma is so serious? I mean the first thing was a cop saying the woman can die over there. . . One of my rotations was at a NYC ER (one of the best in the world), and our main patients were diabetic patients coming in. Do you think it is that serious?
I'm finished P3 and I know Diastat from working in a hospital. We discussed it a little bit in the Medication Errors elective course, but that was an elective course so ~12 students out of 85 went over it.
YES YES YES
A little wishy washy eh?
We got it first semester PY2
Except stopping the seizure
Sorry for picking apart all your post, but my viewpoints really differ from yours. We can argue back and forth about what constitutes a medical emergency, however if in my personal judgment if there were a situation where I had to use a prescription drug on someone to potentially save their life, I would do it. You seem really concerned about the law and liability involved but as mentioned before, the BOP can be flexible in such emergency type situations. I doubt someones ever lost their license for using an epipen on someone without a Rx.
I don't know about other states but in California, health care professionals are also protected under the good Samaritan Laws:
Ann.Cal.Bus. & Prof.Code §2396. Emergency care for complication arising from prior care by another
No licensee, who in good faith upon the request of another person so licensed, renders emergency medical care to a person for medical complication arising from prior care by another person so licensed, shall be liable for any civil damages as a result of any acts or omissions by such licensed person in rendering such emergency medical care.
Just want to add that you can always give glucagon (GlucaGen) injection to an unconscious hypoglycemic patient.
And for patients who are claiming to have asthma attack, then OTC Primatene Mist is a good option.
If a patient was having a true anaphylactic reaction (yes, I have seen them before) I would probably give them the EpiPen - but we learned in class that we are not required to. Technically that would be practicing medicine without a license. This scenario begs the question, "If you have time to drive to the pharmacy to ask for an EpiPen, why didn't you have time to call 911 or go to the ER?" Should I dispense the EpiPen without a prescription I will also call 911 to make sure the patient gets assessed by someone qualified: paramedics and then doctors.
If a patient just happened to walk into my pharmacy and fall down having a major seizure, I would do what any other observer should do: dial 911, clear the area to prevent injury (but don't restrain the patient), turn the patient on his/her side in the recovery position when the seizure ends, protect the airway, etc. I would NOT administer diastat. Having never been trained to administer it nor seen it administered, I wouldn't know how. There ARE risks. Should the pharmacist in that situation perforate the rectum, he or she would be on the hook for damages. Good samaritan laws would not apply since that action is outside of the scope of a pharmacist.
Most things can be taken care of (in urban areas) by dialing 911. Rural areas may be a different story but in towns of moderate to large size, EMS is only minutes away and the reality is...most emergencies can wait a few minutes.
We went over Diastat when we did epilepsy last fall. It is rectal diazepam. It is dosed based off of weight and age.
In rural areas it may take 10-30 minutes for an ambulance to arrive, depending on exactally how rural the area is and where the patient is located. We do have EMTs on our volunteer departments that are usually closer to the patients in the rural areas that act as first responders.
As far as the orginial debate goes, I don't know what I would do. I am not far enough in my career to make that decision, but I do know that I would do anything in my realm of capabilities to help a patient in need.
So at what point would you give it to them? Someone falls to floor and begins having a seizure, you just drop their pants and shove it in? Dear gawd, I hope I never have a seizure in your store.
All4MyDaughter got it right, do what your first aid training has taught you to do. As to the Epi-Pen, there are pharmacies on every corner now a days, the nearest hospital could be much further. I'm confident the BoP would backup any pharmacist use of an Epi-Pen in any reasonable circumstances.
I dont have any problems with the epipen.
About the rest, diabetic comas are not serious if managed correctly. Do not believe the video where it starts off with a cop saying the lady could have died right there. I ve seen enough cases in the ER to think that it is one of those things where although there are risks, it can WAIT 3-5 minutes as in Bayonne nj. Even though we are trained to manage certain diseases like you say, we are not physcians. This has nothing to do with board of pharmacy but playing doctor. If what you said was true, where does the slippery slope end? What about crushing lorazepam or diazepam tablet in water if you dont have diastat? What if a person comes in with a hypertensive crisis (you saw it was >200ish range in bp monitor)? What about an asthma attack? What is to stop you from saying, hey a person has high blood pressure so I gave them durietics without RX. We are taught the appropriate steps to manage a condition, but only so we can further our recommendations.
Concerning the diastat, I would only give it to the nurse. . not to the patient. No wishy washy thing. It is his prescription and in his profile. It is equivalent to me giving a patient enough pills so that they can get the rx refilled. What I am getting from you is that you would give diastat regardless of rx or not and is something I was taught not to do.
My thoughts imo are not that different from all4mydaughters or azpharmd and support their views whole heartly. I would give the epipen as stated before but not diastat (unless in their prescription profile or they have an rx).
I was really just using that as an example, it got blown up pretty quick though. NO, I wouldn't just use it in any case. I'm saying that if it WAS needed and there was someone there capable of administering the dose (ie nurse like in the video or a family member familiar with caring for the patient) then I would let them use the Diastat if they needed it. Hell no I'm not dropping someones pants and jamming something up their ***. I guess I should have clarified that a bit .
lol good clarification.