Trolls, posts and all

[DrDre']

I want to shout out to MMD, JPP, UTSW and Noyac- and to the up and coming attendings on this board. JWK,Trinity, and the pharmacists too.

If it wasn't for the continuing ed i get from you guys, i woul have stopped visiting this board a long time ago.

I am so tired of the trolls on this site.

Why do we attract so many?

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[jetproppilot]

I want to shout out to MMD, JPP, UTSW and Noyac- and to the up and coming attendings on this board. JWK,Trinity, and the pharmacists too.

If it wasn't for the continuing ed i get from you guys, i woul have stopped visiting this board a long time ago.

I am so tired of the trolls on this site.

Why do we attract so many?

Word, Dre.

We'll continue to keep-it-real, posting real life scenerios/thoughts/suggestions for you and your colleagues, even if it has to happen though a pakka-trolls.....

 

[jetproppilot]

Why do we attract so many?

Know what Dre?

Thats a great question that I don't know the answer to.

ER is a board busier than ours....and they don't seem to have the degree of <10-post-I'm-posting-only-to-get-people-angry-a ss holes over there.

 

[DrDre']

I think my somewhat rhetorical question is worthy of consideration.

Is it a lack of respect, the eternal infernal CRNA crapalitious debate, the perceived "easiness" of the delivery of anesthesia, jealous at the $ and perceived lifestyle?

It makes me wonder. No other forum has this kind of routine hazing.

Oh well, back to the Sienna for some rap videos...

 

[UTSouthwestern]

The trolls don't bother me. Shows that our field has a lot of interest, from both our competition as well as our colleagues. I'd love for some of them to nut up and post who they are, where they are practicing/schooling, etc. Mil, Noy, Jet, me, Tenesma, etc. make no bones about who we are and where we practice.

 

[sdn1977]

I want to shout out to MMD, JPP, UTSW and Noyac- and to the up and coming attendings on this board. JWK,Trinity, and the pharmacists too.

If it wasn't for the continuing ed i get from you guys, i woul have stopped visiting this board a long time ago.

I am so tired of the trolls on this site.

Why do we attract so many?

DrDre' - I appreciate you noticing me I try to not abuse the privilege of chatting with all of you and I'm happy to give my statistics to whomever wants them (I've already said I look great in a dress - what more is needed? ) OK - I graduated from UCSF School of Pharmacy in 1977 - have been a practicing pharmacist for 29 years in the SF bay area.....& yes - I have a PharmD.

My husband (a dentist) occasionally reads this thread & his opinion is what occured in his field a few years ago....Dental hygieniest gained the abiity to practice independently & without the supervision of a dentist a few years ago..It caused an uproar in his field - much like yours. However...what happened in actual practice was they didn't want to take on the responsibiltity that came with running a practice - documentation, liability, billing, providing for overhead, scheduling, treatment planning, etc....etc....etc...

His experience is far different from yours, because, like my own surgical experience, we don't choose our anesthesiologists. Patients choose their dentists much like their IM's or pediatricians - they want someone who they can relate to, discuss things with...talk to. However, when I had my surgery earlier this year, altho I trusted my surgeon & had many discussions regarding my surgery....I had only a few moments to tell my anesthesia guy (btw...I did ask if he was an MD/DO & he said there are no anesthesia providers in the hospital I was at who were not) to keep me alive & my brain functioniong - a very short time to develop trust ....& I knew all the awful things that could go wrong! And...as I previously posted...he never made me nauseous - & I never got the chance to thank him for that.

I'm in a bit of the same bind as the rest of you, which, perhaps, is why I like to talk to you all of you (altho we all like drugs I think )....people think my job is just putting pills in a bottle - easy - just like yours - anybody can do it.....until they try to give Lamictal when they meant Lamisil.

So...IMO - you all might have to come from a different perspective - not that my opinion matters one bit. But....as pharmacists...in hospitals, one malpractice case - one situation of administering vincristine intrathecally for example in the case of pharmacy, can wipe out all hospital profits for years (which actually happened in Texas, UT...). That one circumstance alone justified a chemo pharmacist in all hospitals to review chemo orders before administration - which motivated a JCAHO change.

Perhaps you might consider coming from the perspective of what you prevent, rather than what you do, which could provide justification for yourselves (altho I know it is demeaning to have to justify yourself, particularly if you are an MD/DO - but...you are talking about bean counters). Or...as I have asked in a private message to someone...is this a real fear or a perceived fear (as in the case of dentists)? I honestly am ignorant - I don't work with CRNA's nor do I work with AA's in my area. We have OR techs, but they don't administer anesthesia...so there are areas of the country, like mine, which do not see your situations first hand, but appreciate the concerns which are of issue in other parts of the country. I have, however, worked with the bean counters for years and years.....they don't care, for the most part how good you are (or in my case...how much better a drug is even though its more expensive) - they care how you can cut their losses (perhaps a bit jaded on my part). Are there any anesthesiologists who are also MBA's who give an economic perspective to your practice rather than just a clinical perspective - just a thought....

Nevertheless, I do appreciate the cases you anesthesiologis present - they make me think & make me want to give my perspective on what may have happened retrospectively, even though you actually had to act in the moment. THAT is the difference - as MD's/DO's - you know what to do in the MOMENT! - but...that is just my opinion.......not worth the paper its written on (oh - there is no paper )

However....I will say again.....I do appreciate your indulgence in allowing me to venture forth into drug discussions. I apologize for the length of this post and will say - I'm not sure there is any other medical specialty which has the breadth of drug knowledge you folks have & who I have such profound respect for!

 

[dhb]

I think the main reasons for this are

1) this forum is very interresting

2) people on this forum display intelligence and independent thinking and like to sometimes "stir things up" although in an educated fashion which can be disturbing for the ones who have a hard time formulating idea that escape the politcally correct bs.

and lets face it how can you not be jealous of the lifestyle and $$

 

[UTSouthwestern]

But....as pharmacists...in hospitals, one malpractice case - one situation of administering vincristine intrathecally for example in the case of pharmacy, can wipe out all hospital profits for years (which actually happened in Texas, UT...). That one circumstance alone justified a chemo pharmacist in all hospitals to review chemo orders before administration - which motivated a JCAHO change.

Thirty seven documented cases have occurred in the U.S. since 1968, fourteen of them in New England since 1975. However, the majority of these events occurred due to lack of labeling of the medication in a syringe which was confused by medical personnel for an intrathecal preparation of medication and/or delivery of the medication to the wrong patient, not dispensation of an incorrect or incorrectly formulated pharmaceutical. Therefore, does this event truly justify a specialized chemo pharmacist in all hospitals (especially given the relatively low error rate of 37 over 38 years, 14 of which occurred in one state leaving 23 in the remaining 49 states)?

JCAHO's recommendations were, in order, dilution of vincristine into an IV bag, clear labelling of syringes of vincristine with "FATAL IF GIVEN INTRATHECALLY", not dispensing the medication when a patient is scheduled to receive other drugs intrathecally, and conducting a time out during the procedure itself.

Nowhere do those recommendations include a statement espousing the hiring of highly specialized chemo pharmacists for every hospital, and in fact all of the recommendations are processes that can easily be integrated into a hospital or clinic practice.

The event in Texas is one that I am familiar with as the oncologist was a graduate of my medical class and from my previous residency in internal medicine. It was not an error of incorrect formulation or incorrect procedure, it was one of incorrect delivery of the syringe loaded preparation by a pharmacy technician to the wrong patient (same last name, same first initial, both with cancer (one African American, one Anglo American), label on syringe has name and initial, time of preparation, storage/expiration time, but no medication name, concentration, or designated route of administration) and he will forever feel that ultimate responsibility for lethally injecting a patient under his care for what amounts to a clerical error.

 

[Monty Python]

........ It was not an error of incorrect formulation or incorrect procedure, it was one of incorrect delivery of the syringe loaded preparation by a pharmacy technician to the wrong patient ...... label on syringe has name and initial, time of preparation, storage/expiration time, but no medication name, .

Precisely why I don't use any syringe unless I draw it up (I realize chemo agents are in a unique set of rules regarding their preparation).

You find an apparently fresh syringe labeled with a sharpie as "neo." You think it's diluted neosynephrine, but actually it's neostigmine. Oops.

You find a full 20 cc syringe of white stuff which someone else drew up but didn't need. You use it, not realizing it had been drawn up yesterday and you wind up putting the pt in ICU with propofol-related sepsis. There are documented cases of that happening.

While it might upset your hospital's bean counters, I recommend never using a syringe unless you personally drew up the contents. Don't use something you find already drawn up.

 

[Apollyon]

ER is a board busier than ours....and they don't seem to have the degree of <10-post-I'm-posting-only-to-get-people-angry-a ss holes over there.

I don't know why, either - there was one guy 2 years ago (who was trolling me), and he disappeared like a fart in the wind (banned).

So I don't know why, except maybe the trolls don't get the response they're looking for (because people jump on the bandwagon and play into the trolling - like saying to the obscene phone caller "Really? Like, right now??").

 

[sdn1977]

Thirty seven documented cases have occurred in the U.S. since 1968, fourteen of them in New England since 1975. However, the majority of these events occurred due to lack of labeling of the medication in a syringe which was confused by medical personnel for an intrathecal preparation of medication and/or delivery of the medication to the wrong patient, not dispensation of an incorrect or incorrectly formulated pharmaceutical. Therefore, does this event truly justify a specialized chemo pharmacist in all hospitals (especially given the relatively low error rate of 37 over 38 years, 14 of which occurred in one state leaving 23 in the remaining 49 states)?

JCAHO's recommendations were, in order, dilution of vincristine into an IV bag, clear labelling of syringes of vincristine with "FATAL IF GIVEN INTRATHECALLY", not dispensing the medication when a patient is scheduled to receive other drugs intrathecally, and conducting a time out during the procedure itself.

Nowhere do those recommendations include a statement espousing the hiring of highly specialized chemo pharmacists for every hospital, and in fact all of the recommendations are processes that can easily be integrated into a hospital or clinic practice.

The event in Texas is one that I am familiar with as the oncologist was a graduate of my medical class and from my previous residency in internal medicine. It was not an error of incorrect formulation or incorrect procedure, it was one of incorrect delivery of the syringe loaded preparation by a pharmacy technician to the wrong patient (same last name, same first initial, both with cancer (one African American, one Anglo American), label on syringe has name and initial, time of preparation, storage/expiration time, but no medication name, concentration, or designated route of administration) and he will forever feel that ultimate responsibility for lethally injecting a patient under his care for what amounts to a clerical error.

Actually...I think you misread the data. I was referring to the one case which was reported the the Joint Commission Sentinel Event Database. The 14 cases you referred to were reported to England's (not New England) National Patient Safety Agency (NSPA) which had occurred from 1975-2001.

Nevertheless....no matter what your opinion is - yes - these events have indeed changed what hospitals do with respect to the kind of pharmacists who get hired. In oncology centers - MD Anderson, Dana Farber, etc....there are residency trained oncology pharmacists. In small hospitals in which chemotherapy is administered, but not as part of a large oncology service, there is a pharmacist who has specialty training in aseptic compounding which includes not only mixing of chemo drugs, but also the new USP standards of sterile compounding. These events, altho few & tragic, have changed the standard of practice in pharmacy - it may not be enough in your mind to justify the change, but it did anyway.

 

[UTSouthwestern]

it may not be enough in your mind to justify the change, but it did anyway.

and where exactly in my post do you pull that thought out of? I'm talking about your suggestion that every facility that gives chemo, hiring specialty trained oncology/chemo pharmacists:

But....as pharmacists...in hospitals, one malpractice case - one situation of administering vincristine intrathecally for example in the case of pharmacy, can wipe out all hospital profits for years (which actually happened in Texas, UT...). That one circumstance alone justified a chemo pharmacist in all hospitals

I am wholeheartedly for the common sense procedural changes recommended by JCAHO and obviously the pharmacists preparing these medications need to know how to aseptically compound the materials, but what I read in your post was that every facility that dispenses chemo should have a specially trained oncology pharmacist on staff. 37 events over 38 years, 14 of them in one state, with the vast majority being clerical errors, not compounding errors, requires every facility to hire an oncology pharmacist? How about letting the procedural changes take hold first before that?

 

[sdn1977]

and where exactly in my post do you pull that thought out of? I'm talking about your suggestion that every facility that gives chemo, hiring specialty trained oncology/chemo pharmacists:



I am wholeheartedly for the common sense procedural changes recommended by JCAHO and obviously the pharmacists preparing these medications need to know how to aseptically compound the materials, but what I read in your post was that every facility that dispenses chemo should have a specially trained oncology pharmacist on staff. 37 events over 38 years, 14 of them in one state, with the vast majority being clerical errors, not compounding errors, requires every facility to hire an oncology pharmacist? How about letting the procedural changes take hold first before that?

UT - I'm very willing to enter into a discussion with you on the topic of what influences hospital pharmacist staffing, JCAHO accreditation standards for hospital pharmacies or USP Chapter 797 which is the standard that is applied to all practice settings which compound sterile products. However, I don't really think you care that much and it is off the original OP's topic so I would rather it be taken to a thread devoted to that or in a personal message.

Perhaps it is a mistaken impression on my part, but you seem angry with me. Why? What have i done? I appear to have struck a chord with you UT, but it was not my intent to needle you deliberately.

I do believe some people like to witness this form of disagreement (the trolls) and I will not be a reason for this thread to disintegrate into that. The point I was attempting to make was pharmacists were able to use our ability to prevent errors to justify ourselves to administrators. You can disagree that this has any bearing on the case of anesthesia justification all you want - I'd have no way to counter that nor should I. But...if thats what you disagree with - say it.

However, how is the current methods you folks are using to justify yourselves working?

 

[militarymd]

I want to shout out to MMD, JPP, UTSW and Noyac- and to the up and coming attendings on this board. JWK,Trinity, and the pharmacists too.

If it wasn't for the continuing ed i get from you guys, i woul have stopped visiting this board a long time ago.

I am so tired of the trolls on this site.

Why do we attract so many?

I enjoy posting....since leaving academics, my brain has rotted quite a bit...posting makes me think about things that I otherwise would not....so I appreciate people reading and feedback....

As for trolls......what can I say.......but I'm really surprised at the number of people who get sooooo PISSED at me.

 

[DrDre']

It is nice to hear how challenging and stimulating pp can be. In academia, PP is always painted as this easy, less intellectually stimulating environment by academicians.

I enjoy posting....since leaving academics, my brain has rotted quite a bit...posting makes me think about things that I otherwise would not....so I appreciate people reading and feedback....

As for trolls......what can I say.......but I'm really surprised at the number of people who get sooooo PISSED at me.

 

[UTSouthwestern]

UT - I'm very willing to enter into a discussion with you on the topic of what influences hospital pharmacist staffing, JCAHO accreditation standards for hospital pharmacies or USP Chapter 797 which is the standard that is applied to all practice settings which compound sterile products. However, I don't really think you care that much and it is off the original OP's topic so I would rather it be taken to a thread devoted to that or in a personal message.

Perhaps it is a mistaken impression on my part, but you seem angry with me. Why? What have i done? I appear to have struck a chord with you UT, but it was not my intent to needle you deliberately.

I do believe some people like to witness this form of disagreement (the trolls) and I will not be a reason for this thread to disintegrate into that. The point I was attempting to make was pharmacists were able to use our ability to prevent errors to justify ourselves to administrators. You can disagree that this has any bearing on the case of anesthesia justification all you want - I'd have no way to counter that nor should I. But...if thats what you disagree with - say it.

However, how is the current methods you folks are using to justify yourselves working?

Quite the opposite: It seems like you wanted to address me specifically with your address to me in the first post, so I replied. I certainly do not argue that every facility should have a certified pharmacist. Your original post which addressed an event that I was more than familiar with, knowing a physician involved in that case, seemed to argue that a subspecialized pharmacist was needed in every facility that administers chemo.

However, I disagree that a SUBSPECIALIZED pharmacist needs to be in every facility administering chemo if there are capable regular or nonsubspecialized pharmacists in house who are certified to compound the medications and appropriate protocols are in place such as those recommended by JCAHO. It would be similar to my arguing that every anesthesia department or group, or every surgical facility has to have a fellowship trained cardiovascular or critical care anesthesiologist to treat patients that come in with heart disease. General anesthesiologists see these types of patients all of the time and do a great job using the appropriate medications and protocols to ensure safe anesthetics are done. If there is a critically ill patient that a general anesthesiologist does not feel comfortable treating, then you progress to the one with the additional levels of training.

The oncologists select the appropriate medication and the pharmacists prepare the medications and ensure that there are no mistakes in the prescription, dispensation, or administration of the medication. If the oncologic pharmacist can add an extra level of expertise, then that is a suitable reason to have one, but clerical errors that can occur in the presence or absence of a subspecialized pharmacist do not seem to be a problem that needs a subspecialist more than just simple administrative changes.

In your next post, you post somewhat derisively:

These events, altho few & tragic, have changed the standard of practice in pharmacy - it may not be enough in your mind to justify the change, but it did anyway.

As I stated, I do believe the events justify adopting suitable ADMINISTRATIVE PROTOCOLS as laid out by JCAHO, but not necessarily the mass hiring of subspecialized pharmacists, just as I do not feel that every surgicenter or hospital has to hire fellowship trained critical care or cardiovascular anesthesiologists to provide anesthetics to patients with heart disease.

As for striking a chord with me, I would invite you to read my past posts from which you will see that I like a healthy discourse on any topic. I am simply replying to your posts, one of which specifically addressed me about an event, and another which incorrectly interpreted my thoughts about my concern for patient welfare.

If you want to continue this discussion, my PM box and e-mail are always available. As I said before, I don't hide who I am and you are welcome to PM, e-mail, or call me any time to continue this discussion.

 

[BIS]

In my opinion things have been pretty calm on the main forum lately. Dont see to many trolls and the them against us spew has been kept to a suprising minimum. Someone is doing something right. Have a good night.

 

[sdn1977]

Quite the opposite: It seems like you wanted to address me specifically with your address to me in the first post, so I replied. I certainly do not argue that every facility should have a certified pharmacist. Your original post which addressed an event that I was more than familiar with, knowing a physician involved in that case, seemed to argue that a subspecialized pharmacist was needed in every facility that administers chemo.

However, I disagree that a SUBSPECIALIZED pharmacist needs to be in every facility administering chemo if there are capable regular or nonsubspecialized pharmacists in house who are certified to compound the medications and appropriate protocols are in place such as those recommended by JCAHO. It would be similar to my arguing that every anesthesia department or group, or every surgical facility has to have a fellowship trained cardiovascular or critical care anesthesiologist to treat patients that come in with heart disease. General anesthesiologists see these types of patients all of the time and do a great job using the appropriate medications and protocols to ensure safe anesthetics are done. If there is a critically ill patient that a general anesthesiologist does not feel comfortable treating, then you progress to the one with the additional levels of training.

The oncologists select the appropriate medication and the pharmacists prepare the medications and ensure that there are no mistakes in the prescription, dispensation, or administration of the medication. If the oncologic pharmacist can add an extra level of expertise, then that is a suitable reason to have one, but clerical errors that can occur in the presence or absence of a subspecialized pharmacist do not seem to be a problem that needs a subspecialist more than just simple administrative changes.

In your next post, you post somewhat derisively:


As I stated, I do believe the events justify adopting suitable ADMINISTRATIVE PROTOCOLS as laid out by JCAHO, but not necessarily the mass hiring of subspecialized pharmacists, just as I do not feel that every surgicenter or hospital has to hire fellowship trained critical care or cardiovascular anesthesiologists to provide anesthetics to patients with heart disease.

As for striking a chord with me, I would invite you to read my past posts from which you will see that I like a healthy discourse on any topic. I am simply replying to your posts, one of which specifically addressed me about an event, and another which incorrectly interpreted my thoughts about my concern for patient welfare.

If you want to continue this discussion, my PM box and e-mail are always available. As I said before, I don't hide who I am and you are welcome to PM, e-mail, or call me any time to continue this discussion.

Thank you for your invitation - I have