Last night a pharmacist saved my life

The title may be a bit melodramatic, but indulge me if you will.

We've had a trying few days around our house. Heidi's chronic pain flared up pretty badly over the weekend which saw us going to the urgent care clinic, redirected to the ER and then ultimately calling our family friend and doctor from when we lived in Washington to get some relief from what was the worst bout of pain she's had in a while. In the midst of all this, a symptom which Heidi had never exhibited prior to this weekend showed up. It started as involuntary twitching in her left leg and gradually got worse and worse until by Sunday night, she was having full body spasms. These twitches went away when she slept and could be almost "willed away" if she concentrated hard enough. But they were still undeniably there.

On Monday, we went to the physical therapist and the chiropractor. Both provided a great deal of relief, but after a few hours, the twitches were back. The chiropractor recommended following up with our regular MD, saying something about "brain stem lesions" and other such things that sent my brain which, left to its own devices will always concoct the worst case scenario, into hyperdrive. His thought was that the MD would refer us to neurology which seemed appropriate to me.

So we did just that - we visited our MD yesterday and he did just what we expected and referred us to neurology. He sent Heidi back over to the hospital for some bloodwork to rule out some of the more obvious things. I had left work to accompany her to her appointment and she sent me back to work as my presence at blood draws is not essential. I did, however, leave her in a wheelchair in the front lobby of the hospital. Jeez, what kind of husband abandons his wheelchair bound wife to go back to work? What a cad.

That was, until going back to work caused a light bulb to go on over my head.

I'll admit that I had thought of it previously, but had dismissed it. Heidi takes Effexor for the fibromyalgia-like pain that she has. She takes a mid-range dose as that's the dose where you get the effects for pain vs. the mood-elevating effects of its approved indication for treating depression and anxiety. She also takes trazodone at night, which is an old time antidepressant that we don't use anymore because the doses needed for effective treatment of depression are so sedating you end up looking like something out of The Walking Dead. However, it does have a place in treating mild insomnia which is what she'd been taking it for. She had been taking 25mg of trazodone at night, every night and had recently upped her dose to 50mg. In addition to this, she had been tweeking her dose of Effexor upward as her pain had been bad.

What's important to know is that both of these drugs affect a neurotransmitter called serotonin. What they do, in effect, is keep serotonin in the neural synapse instead of allowing it to be taken back into the neuron for reuse. This is what leads to the mood elevating effects you see with these drugs. Why the hell this works for pain is a fuck-if-I-know type thing, but it does. Sometimes, when you combine these drugs, you can get a drug interaction which leads to an excess of serotonin. Basically think Duran Duran's "Too Much Information" but instead "Too Much Serotonin."

This condition is what's known as "serotonin syndrome." When I looked up the interaction between Effexor and trazodone, I found the following:

Symptoms of the serotonin syndrome may include ... neuromuscular abnormalities such as hyperreflexia, myoclonus, tremor, rigidity, and ataxia.

It was a long shot - especially at the low dose of trazodone she was taking and there were many other symptoms she didn't have, but something easy and worth a try. I had her stop her trazodone and the doctor was already having her back her Effexor dose down to 150mg. The half life (the amount of time it takes half of the drug to be eliminated from your system) of trazodone is 3-6 hours and it's generally accepted that for a drug to completely clear your system takes 5 half-lifes. So if my theory held any water at all, about 30 hours from when she took her last dose of trazodone, her symptoms should really start abating.

We're past that point now, and her twitching is all but gone. She's gone from needing a wheelchair to get around to nearly baseline in that time. I'll never be able to prove definitively that I was right, but in my mind, I was. Nothing else changed. And as House always says, it fits. Mostly, I'm just glad that she's on the mend.

I always get ticked by the way the movies and TV portray pharmacists - you know, as nerds behind a counter without a single ounce of social skills. They are invariably balding middle age men with thick glasses that don't seem to be using their brains. Nothing could be further from the truth. I do this kind of stuff every day. Mostly, it is mundane stuff that is easy to catch and any pharmacist worth their salt will see it. But every now and then, I get something like this. And it makes all those years of fancy schooling worth every penny.

So hug your pharmacist (especially if I am your pharmacist - I like hugs) because some day, they might just save your life. Or at least stop you from twitching.

Get the point? Good. Let's dance.

Pharmaceutical influence

This is National Hospital and Health-Systems Pharmacy Week, or as we like to refer to it Pharmacy Week. We're having a potluck at work tomorrow (which reminds me, I still need to hit the store for my contributions) and the techs at work all have t-shirts that they've gotten the approval of administration to wear through the week. I don't know if retail pharmacies are celebrating this week, but we are.

I've said it before that if I had it all to do over again, I wouldn't change a thing (cue Kylie.) And it's true, I wouldn't. I can't imagine doing anything other than what I'm doing right now. Being a pharmacist is so much a part of who I am that doing any other job is just an alien concept to me. There are days that being a pharmacist makes me crazy, but I imagine that it's no different than any other profession - you have your good days and your bad days. But the simple fact of the matter is that I am well suited to this profession both because I am smart enough to do it competently and because it fits in with my personality quite nicely.

If you can believe it, there was a time that being a pharmacist wasn't even on my radar. For most of my high school career, I was interested in going to medical school. I was always pretty bright and I was interested in science so I figured why not dream big? That started to change in August before my senior year of high school started when I got a call from a local pharmacist offering me a job. He owned a small pharmacy that was attached to a medical clinic in the town I grew up in. Each year, he hired a high school senior to work in his pharmacy doing deliveries, waiting on customers, restocking. What it amounted to on the surface was performing rather menial tasks but it was also an opportunity for him to give back to the community as a local business owner. Unfortunately, I had already signed up for community college classes that were in the evening, so I turned him down. However, my folks encouraged me to call him back and see what it was all about. I did, and after a very informal interview, he hired me on the spot for $3.60 an hour. This man's name is Don Jones.

It's fairly safe to say that I wouldn't be a pharmacist today if it hadn't been for Don Jones. The more time I spent in his pharmacy, watching him do the job he did, the more I realized that this type of health care profession was really much more my speed than any other I could get into. I was fascinated by drugs and how they worked and learning what they treated. I remember taking package inserts off the bottles and putting them in a file folder at home so that I could learn more about the drugs I was stocking every day. Don nudged me along the road to choosing pharmacy as a career very subtly. When I finally spilled the beans and said I had changed my mind, I think he was a little bit surprised. After I graduated from high school, Don hired me back every summer and Christmas vacation (and some spring breaks) until 1995 when I finally graduated with my B.S. in Pharmacy and he sold his pharmacy and subsequently retired. It was his influence and quiet role as my first pharmacy mentor that really set me on the path that ended up with me becoming a pharmacist rather than a very unhappy M.D. It's quite possible I would have seen the light along the way, but because of him, I didn't have to do it that way.

If Don Jones is responsible for me becoming a pharmacist, then John Hamiel is the reason I'm the type of pharmacist that I am. John was my boss in my first "real job." Looking back, he was my boss, my colleague and my friend - a situation that required him to wear a lot of hats. He was also, oddly enough, one of my students when I T.A.'d the P4 parenterals lab at the U of Iowa College of Pharmacy when I was doing graduate work. This just goes to show you that you should be nice to everyone you meet along the way because you never know when they might become your co-worker or even your boss. This is doubly true in the small world of pharmacy.

Anyway, the notable thing about John is that he really took a chance on me when he hired me. Here I was, applying for a hospital job with zero hospital experience. My only real pharmacy experience was retail, which included the years I'd worked for Don Jones and my part-time job at Drug Town in Iowa City that I used to help pay the bills while I was getting my Pharm.D. But for some reason, I didn't want to do work at Hy-Vee my whole life and on the encouragement of my friend Dr. Lynette Iles, I applied for the hospital job where John was the soon-to-be director and Lynette was on the medical staff. Despite my lack of experience, I got the job.

I am fond of saying that retail pharmacists and hospital pharmacists may both be pharmacists, but they speak in totally different languages. The learning curve I experienced my first year in a hospital setting was a steep one, indeed. There were times that I didn't think I could do it. When you work in a hospital, there's a whole subset of drugs that you never see in community pharmacy. The patients are (naturally) sicker than they are in an outpatient setting, so learning that sometimes we can do everything right and still not save the patient was hard for me. It's still hard for me. I think if it isn't hard for you, you need to check and make sure you still have a pulse. But John was always supportive and helped me learn lessons not just about hospital pharmacy but in the politics of working that everyone needs to get at least a little bit good at. Both sets of lessons ended up being invaluable.

My practice style has been so influenced by John that sometimes I find myself saying things that he said, even saying them like he said them. In a lot of ways, he was kind of "future me" although I didn't realize it at the time. We got along well and shared a lot of the same geeky humor and interests that define some of the strongest friendships I have. It was hard to leave when it came time for our family to change our scenery and move to Ames. But I owe him a debt of gratitude. Because he took a chance on a 27 year-old newbie, I've learned more about pharmacy than I ever thought I would and have more knowledge in my periphery than I thought humanly possible.

So during this Pharmacy Week, I want to take this time to say thank you to both of these men who were friends and mentors to me. Their influence is palpable in my life and career.

And because we don't want to be too serious and because I still have a 12 year old boy in me somewhere, here's the Top 11 Reasons to Date a Pharmacist:
1. Pharmacists do it twice 3 times daily
2. You can see your pharmacist the night before the morning after.
3. Pharmacists have a long duration of action.
4. Pharmacists are Rx rated.
5. Pharmacists find new routes of administration.
6. Pharmacists do it over-the-counter.
7. Pharmacists are patient lovers.
8. Pharmacists accept 3rd parties.
9. Pharmacists have a quick reconstitution time.
10. Pharmacists do it without breaks.
11. You will want no substitution

Happy Pharmacy Week to all my pharmacist friends and colleagues!

(Hug your pharmacist today. Especially if that pharmacist is me.)