Pharmacy. Jim Plagakis. Pharmacist

I was talking in an e-mail to Margaret Mulligan about a column idea for JP at Large in Drug Topics.  She asked about counseling and if I had time to counsel properly.  I told her about the weeks right after Hurricane Ike.  The store where I work is at the east end of Seawall Boulevard.  It is the UTMB/historical district.  There are incredibly nice vintage homes that are owned by people with money.  Doctors, scientists, nurses, professors, faculty.  Most of the homes were low enough to get up to five feet of flood.  The UTMB clinics were moved temporarily to the mainland.  We had plenty of time to counsel

I told Margaret that I counseled like a madman.  The prescription mill was slowed way down.  I jumped at the chance to counsel on Cialis and Viagra.  It was fun to take the gentlemen aside and warn them to call the doctor if their boner lasted more than four hours.

“Oh, you are  kidding.”  Around the World in 80 Days buy A huge grin.

“No, scouts honor.  Four hours.”

“Oh, you silly boy.”  Giggle, giggle.

“Keep the huffers in the drawer,” I warned.  (Huffers-Amyl Nitrate inhalation glass crushable things)

“Oh.”  No giggle this time.  “Oh, my dear, thank you for the warning, but why?”

“You could drop dead, then what good would the four hour boner do you?”

“Oh.. dear me.”

I remember counseling a couple on Cialis.  They were especially thankful of the huffer warning.  They all dressed and ready to muck out the house.  There is a very robust older gay community in the historical district.  This couple was 50 something.  They were soft-hand professionals but they wore work clothes.  The “wife” was color coordinated right down to his socks and head band.  Yellow and orange.

On second thought, perhaps this is not for JP at Large.

 

 

The Cycle (aka The Devil’s Ground) release

2008 was a terrible year.  I can group it in with other horrific years.  Namely 1950-1951 when I spent months in the hospital with polio.  1968 was terrible and I have talked about my first wife Donna before.  1999 was just very bad, not terrible.  I was living alone in Bellingham after leaving my second wife.  I do not do well alone and I was really lonely. 

I asked a much younger woman out for lunch and a movie.  She refused, but did it in a patronizing manner, like I was one of her father’s pervert friends.  I asked an older woman out for lunch and a movie.  She accepted.  I looked forward to the date.  A guy named Bruce came in the drug store.  With a shaking hand, he waved a bony fist at me and announced that my date was cancelled.  I volunteered for a literacy project and I asked a plain, librarian-like out for lunch and a movie.  She laughed and said that she liked girls.   I gave up.

The apartment in Bellingham was very nice.  It had plenty of room for when my daughter visited, every other weekend.  I lived for those visits and put up with a teen ager who treated me badly, taking the cue from her mother.  She was her mother’s hatchet girl.  1999 was vindicated when I met Victoria in September and married her in December.  Most of the next 9 years were deep in the rabbit-hole.

2008 was horrible.  You can tell by how I feel six weeks into 2009.

January, 2008, I was riding my bicycle on the seawall when I came upon a truck illegally parked on the wide sidewalk.  Rain had just started and I was 6 blocks from 75^th Street.  I was peddling as fast as I could when I came upon the truck.  I moved out onto the parking strip.  I took a very wide angle back onto the sidewalk and went down with a thud.  I was wearing short pants.   My left knee was so badly scraped that I could see the meat.  Betadine in the shower and I went to work that morning.  Talk about being institutionalized!  I was in shock.  I sat on a stool and checked the technician’s work.  My left pant leg was soaked in blood.

By the time I was “healed”, along came September 13^th and a Hurricane the size of the state of Texas came barreling ashore just 2 blocks from our townhome.  Dealing with the storm, FEMA, SBA and insurance companies is very difficult,   It is a stress that is unmitigating.

Our dead bodies are still under miles long debris piles on the mainland or were swept out to sea.  If there are no corpses stretched out in unbecoming positions, then there is no story for the national media.  Or so it seems.  The story of Galveston and Hurricane Ike lasted about two weeks.  It had just started for us down here.

The presidential election took everyone’s attention and Galveston seemed to be left on its own.  There was big, blustery talk from George W. Bush and from Texas Governor Rick Perry.  But their lofty promises were for the media.  FEMA?  Well, FEMA is FEMA!  Insurance?  They grow small print like Kentucky grows tobacco.

           

Galveston is not New Orleans and Hurricane Ike was not Katrina.  Not one inch of Galveston is below sea level.  Pumping was not needed.  The water subsided rather quickly all by itself.  The enormity of the disaster was not noticeable right away in the city.  The buildings in the historical district looked to have survived.  When you look inside, however, there is black mold and toxic mud.  In the neighborhoods, the loss of every single thing you owned in most ranch style homes.  The fifteen foot flood surge came mostly from the bay side.  The famous Galveston seawall did its job.  It held back the bottom seventeen feet of surge from the Gulf of Mexico.  Otherwise, I would be homeless.

           

The storm was enormous, 900 miles across, the size of Texas.  We evacuated on Friday morning when we saw that the water from Offat’s Bayou was already up to our driveway which is ten feet above sea level.  When I heard the words surge, death, storm and certain all in the same sentence, we headed for the Texas hill country where a relative I share a great grandfather with offered her guest house.

We lived in relative luxury for seventeen days with our anxious eyes on 24/7 storm news. 

 

We were always home at 1:00 PM to see the daily Galveston new conference.  When the mayor finally said we could come back, we returned wide eyed on September 25^th.  We had to drive around debris piles and downed electrical wires.  The only dead body was someone’s sheep dog.  Our home is one block from the seawall.  We feared that it would be too damaged to live in.  The first level is garage and storage.  We lost a car.  The upstairs was as we left it.

 

The media missed the story of one dead body.  The owner of a local deli rode out the storm at home.  He waded through waist deep water contaminated with sewage and disease to see his store.  He had a small cut on his leg.  A flesh-eating bacteria set in.  They amputated his leg when antibiotics did not do the job.  Then he died.

           

There was no one else living within blocks for the first week or so that we were back.  We were all alone and we carried on with a four plug generator and a couple portable air conditioning units for the sleeping rooms.  We had nothing else.  The cell phone was our only portal to the world.  We ate cold food mostly and heated our nine month old grandson’s bath water on a hot plate.  The water was dangerous, not drinkable.  We brushed our teeth with Dasani. 

           

Our personal grooming suffered.  You just don’t get as clean in a cold shower.  Our intestines stopped working properly.  The night took on the shadow of dread. Any noise outside terrified our fatigued minds.   We imagined modern demons and felt an unreasonable fear of ill-defined danger.  We dreamed dreadfully.  Fight or flight, but there was no place to fly to.  At night, we were pioneers in unexplored regions.  The dark breeds terror.

           

I didn’t like the flies that were breeding in the debris piles.  Black, fat, slow-moving flies.  Little gnats filled the kitchen.  They got in my nose.  I found my pleasures in simple things.  I usually get up early, before the sunrise.   I would take a cup of strong coffee (made using electricity from the generator) and, in my pajamas, I would go down to the neighbor’s at the end of the row and sit on her stairs (to get away from the noise of the generator).   What struck me was the out-and-out blackness all around me.  It had its own kind of unexpected beauty.  There were no house lights, no street lights.  No lights at all.  I had no choice but to just be there.  There was peace and a luxurious calm.  The pleasantly hot morning air held the smell of decay, like a garden in decline.  

           

I looked up and found the amazing universe one morning.   I had lived in or near a well-lit city for so many decades that I cannot remember ever seeing so many stars.  Right away, I found the Big Dipper.  It was right where my father told me it would be.  Cabin Boy download

           

I took out my cell phone almost every morning and called my brother in Stowe, Vermont.  I liked to tell him about Galveston, that boozy-eyed older woman with too much makeup on her broken face.  Her heavily red colored ruby lips curve into a crooked grin.  I can hear a sultry whisper, “Don’tcha wanna dance?”

 

V and I made it.  The recovery and repairs to our flooded lowest floor were complete in January.  Insurance refused us.  “You don’t live down here.”  The flooded area was the garage, hallway, a large storage room and 2 small ones. 

 

It is 2009 and I think that I can go on. 

 

 

 

 

 

“He say he don’t have the money.” The speaker was the only one of the group of three storm-recovery workers to be literate in English. He had a pained look on his face. The patient looked worse.

“I didn’t think so.” I advised. “I’ll call the emergency room and get the doctor to prescribe something less expensive.

The Rx was for Levaquin 500 mg and each of you knows how fast you can get to two bills with that “wonder drug”. You also know the kind of crusade you often have to go on to get anything from the ER.

First, I had to go through the main UTMB “switchboard”.

I finally said, “Patient care is the only thing that is important. This man is not getting rich mucking out flooded buildings. He paid for his ER visit and he cannot afford the antibiotic.”

The nurse said, “That doctor is long gone. He won’t be back for two days.”

“Do you think that the doctor really wanted to treat this guy for his infection?”

“Of course.”

“Well, he must have missed the day in Patient Care Class when they talked about the patient’s pocketbook and making sure the patient can actually afford the medicine.”

“That’s rude.”

“Bingo!” I said, “When I am advocating for a poor patient who sends most of his wages back to Guatemala, I have been known to be disrespectful, boorish and rude.”

“Well you are all three.” Huff, huff.

“You are taking this personally. Don’t. I did not say that you have a wart on the end of your nose. All I want is 3 minutes with the guy who is the ‘attending’ right this minute.”

“You will have to wait.”

And I waited…..and waited………and waited. Why. Because this poor bastard from Guatemala was, at the moment, a VICTIM of the American way of medicine.

Finally, I get the doctor. He listens. “Doctor Collier is gone.”

“I know he is gone. I am asking YOU to prescribe an antibiotic that the patient can afford.”

“Well…… I don’t think I should change Doctor Collier’s orders.”

“Then the patient gets nothing.”

Silence, then, “How much does Levaquin cost.”

I told him the cash price. Over $200.00.

“No shit!” His voice changed a bit.

“No shit! Doctor, if you do not have insurance in the good old U S of A, you are screwed.”

“What about Doxy?”

“He can afford Doxy. I thank you and the patient thanks you.”

Just one more challenge to the pharmacist, at the bottom of the funnel. That is where we live, at the bottom of the very full funnel. We get all of the sediment from all of the other medical disciplines. If the patient just doesn’t have the money, we can help. And we better help because no one else will.

Tell the prescriber, You gotta get the pill in the patient’s mouth or your whole trip is a waste of time.

I want to follow up on my sexy little essay down below.  I know that I am not alone in having dalliances at the pharmacy.  Pharmacists have been doing this all along.  Now, we have female pharmacists who are the boss.  Whadaya think?  That their blood is cold?  Doctors have been bedding nurses for decades.  Lawyers have been banging the secretaries. 

I have been in the pharmacy universe for 53 years.  My first job was as a “Stock Boy” when I was 15 years old.  My first RPh registration was in Ohio.  August, 1964.  The “drug store business” is the only thing I have ever done to make a living.

I have made a lot of mistakes.  I have done a lot right, but it is the dumb things, the stupid things that stick with you.  Perhaps you will get some good from my blunders.

You know about this one.  Don’t nail the help.  You men know better, but you girls are treading in unsafe water if you have a quickie with the intern from Ohio Northern.  Sexual harassment works both ways. 

I had a good management job at a chain drug store that was five minutes from my house.  I was in it about 15 years.  I had a month’s vacation. I really was set.

I had a hissy fit over middle-management cutting the two day a week part time RPh.  I was self righteous.  I had a stuffed-full bag of resentments.  I fought and lost.  Rather than back off like a smart rat.  I was dumb. 

Highlander the movie

I just quit.  The old I’ll get you, you SOBs. 

This job was on Whidbey Island.  At the time, there were only six pharmacies on the island.  I ended up working in Everett, Washington, on the mainland.  A 90 MINUTE COMMUTE.  One Way!

Lesson to you:  Do NOT quit a job until you have your next job waiting for you.  Two weeks’ notice?  Why do you have to give notice?  Would they give you a 2 week warning if they were firing you?

One more mistake for today?  My first job was a union job.  I was ambitious as one could be.  I jumped at leaving the union job for a management job with a large big box before they were called big box.  The guy I worked with had no ambition.  About ten years ago, I talked with him.  He was 62 years old and retired.  He stayed with the company and the union for the whole ride.  He had medical that will last until Medicare for both he and his wife.  The union would pay for the Medicare supplement.  He had a nice pension from the union and his 401k was hovering around $750,000.00.

So, who was the smart one?  Who made a mistake?  Certainly not him.  I’m still working.

 

 

I like to be friendly and helpful with everyone, but I pick favorites.  I know we are not supposed to do that and that some of us pretend that we don’t pick favorites.  I think that everyone does.

During my career, I didn’t even pretend that I was an “equal favoring” boss.  I was not.  It was a mistake and I had to pay for it at times.  There were two instances in particular, at two management jobs.  One in San Diego and the other in Pacheco, California.  I favored the woman I was having sex with in both jobs.  I was in my mid-thirties, single.  What do you think I was going to do? 

Cabin Boy buy

I am telling you this story because there are 30-something men and women out there, in positions of authority, who have nice, lusty red blood running through your veins.  At the end of a long, tough day of multi-tasking, is there anything wrong with looking at your tech, touching him/her on the forearm and saying, “Let’s go get a bite and a drink.  My treat.”

Of course there is nothing wrong with it.  My problem was that with the one in San Diego, I invited her to my place for a drink and carry-out Chinese.  The Chinese got cold, we had two or three drinks and it seemed normal that we were sitting on the floor, touching each other.  She touched me and I touched her and she started on the buttons on my shirt and I started tugging at her shorts.  The music was Richie Havens. 

After, I said, “That was nice, but we did get carried away.”  I was pulling a tee-shirt over my head and she was shimmying back into her short pants.

She said, “Hmm hm” and nodded with a knowing smile. 

I stammered, “Uh, I mean, uh, we are both adults and this can’t happen again.” 

She just smiled and nodded like I was telling her a secret.

“We have to be business-like from now on.”

She smiled and moved in for the kill. She gently put her knee between my thighs and I became Jello.  She kissed my mouth and started peeling the tee-shirt over my head.  We went back into the bedroom and did it again.

The one in Pacheco was a 23 year issue.   We had sex for almost two years before I married her.  In the beginning, we had a nice marriage of convenience.  She and her two year old daughter made me feel, needed.  Years later, the girls were grown and I lost my reason.  My wife told me that she didn’t need me anymore and that was that.

The moral of the story is Don’t!  Do not start a sexual relationship with the help.

I was a good guy.  I was single and the two women were single.  I know pharmacists who are married who have sex with employees who are married.

One guy told me that he could not stop because his manhood was at stake.  A woman told me that her husband not only was living off her, but that he abused her.  I warned her that her husband may be out to abuse the store assistant manager if she didn’t look out.  Lord of the Flies full

I will be surprised if there are any comments on this.

 

 

 

This letter came a couple days ago.  I have the writer’s permission to repeat it here.  Will you help out with your advice?  200 hours could be $12,000.00  After I hear what you have to say, I’ll post my advice.

Jim,
 
 I need to ask you a quick question. I am, with all certainty, 
 resigning my position as pharmacist-in-charge as well as my employment 
 at the end of the first week in March from the employer you so very 
 much pleaded with me to leave a couple of years ago. I have finally 
 reached to tipping point. We will be finally reopening our store 
 after it was destroyed in a flood in August of 2007. The big move 
 will take place at the end of the month and I want to be there for the 
 grand reopening as I have worked very hard to help restore the 
 customer base to where it was while doing business in a small rented 
 place.
 
 My question is this. I have accumulated over 200 hours of vacation 
 time that is printed on my paycheck stub as vacation. When I resign, 
 is there any way he can screw me out of that part of my severance?

 

Some of you have asked me what to say to a patient who is terminal.  These questions are in response to the essay I wrote on the page up on top entitled “Terminal”.  Take a look at that piece, then read this.

Let’s use cancer as the focus.  Most important is that you understand that terminal patients just might not be terminal.  These days, who knows?  Then you have to understand that a cancer patient is fully alive, just like you.  They have the same hungers and appetites as ever. 

Their sex lives can be an issue.  Their spouses or lovers may get the “willies” just touching them, as if the cancer is oozing out of their pores. 

Their friends can be an issue.  They avoid their friend with cancer simply because they don’t know what to say.  I believe that the majority of friends of terminal people would rather not know anything. 

Many cancer survivors say that what they want most is to just be heard.  Truly listened to!  They want understanding. The last thing they want is being told what to do or how to cope.

Try these:

*Show some empathy.  “I’m sorry to see that you are dealing with cancer.  If I can do anything for you, please do not hesitate to tell me.  Then… just listen.

*Don’t forget them.  When they are in your store, walk out and take a few minutes.  They can feel that they have been cut off from their friends.  It may be more the truth than a feeling.  Listen!

*Offer specific help.  The sentence up above should be followed up with a specific suggestion.  Tell an isolated patient that your delivery person will drive them to some appointments if needed.  Your teen age son is available to mow the lawn.  Your spouse has offered to cook some meals.  Be creative.  The patient may never accept, but will feel valued from your offer.

*It is best to keep Prevention magazine cures to yourself.  Don’t recommend herbs unless they ask for your advice on non-mainstream treatments.

*You don’t have to talk about cancer.  Sports or entertainment will keep them engaged.  You are creative. 

*Include them.  If they have become a friend, treat them like a friend.  Share a meal at a restaurant.  Go to the museum.  They won’t feel isolated even if they decline.

*Their friends just may have their heads so deep in the sand that they don’t realize when something good has happened.  Hair comes back.  So does strength.   Be happy for them.  Shake hands, give a hug or a high five.

That’s a start.  Be respectful.  They may not want to talk.

This came in an e-mail from Margaret Mulligan, the Editor of Drug Topics magazine. 

...I have entered your columns in the Neal Awards, which is the big-time “Pulitzer” of the trade press:
Cabin Boy movie full
 

Under Siege 2: Dark Territory download

In JP At Large, Drug Topics readers encounter a colleague who says things they would say out loud—if they could. In his monthly column, Contributing Editor Jim Plagakis, RPh, interweaves his personal and professional experience to make timely and pertinent points about the state of pharmacy practice. This sampling [May, June, Sept, and Oct] illustrates that while Jim is not always politically correct, he always zeros in on issues of importance to our audience.

You are most likely a mandated reporter.  Pharmacists are on the list in the laws of most states.  When you see child abuse or neglect, you have to report it to stay legal.  You may not have known that.

Around Christmas 1995, the chain drug store where I worked put ends of toys all over the store.  There were two right near the pharmacy.  One was a display of dolls.

I was working away one evening.  Getting g an order together for a regular customer who worked for Child Protective Services.  This was in Washington State and, as usual, this state employee had police powers.

All of a sudden, there was a huge fight.  “I told you not to touch.”  Slam, Bam, Bif.  “How many times do I have to tell you?”  Ka-Bam, Huh.”

Scary Movie 3 move

“Oww, please, Mommy.  Please don’t hit me.  I’m sorry, Mommy.”  This small five year old  was pleading with her mother.  “I won’t touch.  I promise.”

These were no slight slaps.  They were big hits with an open hand.  The kid went to the floor and refused to get up and the mother lost it.”

She kicked her little girl.  I was frozen.  I wanted to do something, but what?

“You’re gonna learn.”  Slap, Bam, Bif.

That was enough for my CPS patient.  She stepped over, shoved her badge in the woman’s face and arrested her.

The five year old went to foster care awaiting the court’s judgment on the mother.  There was no father in the house.

Star Trek: Nemesis film

The DPS patient told me that I am a mandated reporter.  Later, she sent me the law.  I asked her if I was supposed to do something when a parent spanks a kid in the toy aisle. 

Shoot ‘Em Up psp

“Legally yes, but a drug store is a different environment than a doctor’s office or an emergency room.”  Her look told me that she trusted me to make the right choices.

I did, only once.  I was living in Oak Harbor, Washington, the home of Naval Air Station Whidbey Island.  The interesting twist is that the kid who was getting beaten was a close friend of my 12 year old daughter.  She broke down one day and told my daughter what her Navy sailor step-father was doing to her.  Christy told me.  To be fully accurate, the mother and kids were Filipino.  The step-father was pure white American.

The mother and the girl came in one day.  They said hello.  I was a good friend’s father.  I saw the bruises on her legs where the shorts did not cover.  Her neck had bruises like strangle-marks.  I asked.  The girl looked down to the floor.  The mother said that she had fallen.

I called my DPS friend.  She did not take action herself.  She paid a visit to the sailor’s commanding officer.   The entire family was in counseling three days a week, starting immediately.

That’s all I know.  Angie was pissed off at Christy for telling me.

What would you do?

 

 

• Speak move

This is the column that got tons of hate mail from clinical types who probably have never had to write a check for the wholesaler’s invoice.   This column got a lot of hate mail from clinical types who have no clue what it is like to pay the wholesaler’s invoice and still have payroll to make.

They said that we should do anything, at any expense, to satisify the doctor.  Judy Chi, the then editor of Drug Topics, jumped me as if I had planted a bomb in the editorial offices.  

This column also got tons of good mail from pharmacists who know what it takes to pay those wholesaler’s invoices.

Column # 164                                                                                                 Jim Plagakis

 

How wrong could I be?

 

            It has seemed to me that doctors are pretty much taking off the

better-than-you crowns and the are-you-looking-at-me cloaks these days.  They seem to be much more egalitarian than ever before.  They often seem to be more democratic than they were just ten years ago.  I can even call them by their first names without getting attitude.  When I question them on restricted refills on something like Freestyle strips, they are likely to back off and change to PRN.   Doctors are getting human on us. 

            I know!  Watch out that you don’t fall down laughing.  I was brought back down to reality recently.  This guy on the telephone starts asking about prescribed medicines

for his brother who was just released from a hospital about 40 miles away.  The patient needed to get home to Ohio and the brother wants to get going on the long road trip.  I should have wondered why he was calling me when there are plenty of drug stores closer than 40 miles.  Was I the last resort?

            “Do you have Keppra?” he asks.  “My brother needs 60 tablets of both 250mg and 750mg.  I’d like to pick them up before you close.”

            “We do not have either,” I said.  “We do get a morning order by 10:00 AM,” I wanted to help.

            “He also needs Diastat.”

            “That is hopeless,” I said, “I doubt if you will find any drug store with that in stock.”

            “Why  not?”  Did I smell a haughty attitude?  The odor is unpleasant.

            “Pharmacies don’t keep it in stock because it is rarely prescribed and it is very expensive.”  I walked to the order computer.  I was anticipating the next question.

            “What is expensive?”  Oh, there was the attitude, loud and clear.

            “How about a wholesale price of $320.00 for a 20mg twinpack.  That’s just two doses.  There is not a pharmacist alive, with any sense at all, who will keep Diastat in stock.”

            “Isn’t that a pharmacy’s duty?” he demanded, “To be adequately stocked?”

            That was enough for me.  “Man, who do you think you are talking to?  I have been doing this for a long time and I’m not going to let anyone question me like that.”

            A silence, then this.  “I am Doctor Michael Stewart, from Michigan.  My brother needs these drugs and I want to leave for Ohio by noon tomorrow.  My brother has Humana insurance and I want to pay only his copay.”

            “What you want and what you get may be two different things, Michael.”

            A long silence.  “That’s Doctor Stewart.”

            “That is going to get you even less.” 

I was swiftly punching numbers into the calculator.

            Like a smart rat, his tone changed.  I might have been his last resort.  “Can you guarantee that you will have these drugs by ten tomorrow morning?”

            “I won’t guarantee anything.”

            “But you said ….”

            “… Let’s get real here.  You are asking me to invest, in wholesale prices, $320.00 for the Diastat and a total of $829.00 for both strengths of Keppra to make a Humana profit of maybe $50.00, if we are lucky.  That’s an investment of more than eleven hundred dollars, Michael and we leave $400.00 on the shelf.”

            He argued.  “You are a pharmacy.  It is your job to care for your patients.”

            “This patient is not ours.  He’s from Ohio.  This is Texas.”

            “He is a patient in need.  Doesn’t that mean anything to you?”  Oh strum those heartstrings, Michael.  Guilt quit working on me when I left my second wife.

            “I’m not going to ask my owner to eat $400.00.”  By now, I was actually getting a kick out of this conversation.  He did not know it, but our talk was long over.  I needed a little fun near the end of a hectic Friday, but the sunuvabitch ruined it.  He hung up on me.