When you've had more coffee than usual and…
You know how when you've had more caffeine than usual, and you're just barely past the edge of high-performance into the realm of "Hmm maybe I've had too much coffee"?
And then you get some unexpected, bad news out of left field that would make you feel pretty shitty without that extra stimulation, but because you've had more coffee than normal your baseline sympathetic tone is already elevated, and all of a sudden you've got skeletal muscle tremors and you can't sit still to save your life or focus on any one thing for more than 4 seconds and your hands are cold and clammy and your knee is going a mile a minute and you have to piss every 20 minutes which smells like the Kilimandjaro dark roast you just had?
Yeah, that's where I am right now.
How-To: Find the best Medicare Part D prescription drug plan
So we're in the open enrollment period for Medicare Part D. It started on November 15, and it ends on December 31. I've been doing consulting twice a week, and the scramble is in full effect. While I do quite a bit more than plunk in drugs and quantities for my consulting, there is one tool that is the backbone of what I do when running various scenarios. It's the Medicare.gov plan finder.
This guide does not apply if you have a hybrid medicaid-medicare plan through your state. Those folks know who they are, and if you have no idea what I'm talking about, you don't need to worry about it.
Before you begin you'll need three things:
- A complete drug list of the person you're doing the research for. This means you'll need drug names, strengths, and quantities. Calculations are done for a 30-day supply, so if you take something 3 times a day, the quantity for 30 days will be 90.
- About five minutes
- An Internet connection (har har)
Here's a walk-through, so you'll want to open the link in a new window or tab…
Happy Thanksgiving, everybody
I have a lot to be thankful for this year. More than in any year in recent memory, despite some small setbacks. I'd bore you with the details, but things are a-happenin' in the kitchen, so I'll leave you with this comic that made me giggle.
Be well, my friends.
On the list of things I expected to hear today, this was not near the top
I'm was a little upset this evening, but I'm getting more comfortable now.
I called my GI doc three days ago to discuss my ongoing issues, and I was able to get an appointment for this afternoon(!). The nurse that did the preliminary vitals and whatnot stuff was unfamiliar to me. She told me that the GI folks were borrowing her for the day from Cardiology downstairs. For some reason she decided to listen to my heart… and she took a really long time doing so. I don't remember anyone listening to my heart before except at my PCP's, and never for so long.
"Hmm," she said.
"'Hmm'? What does 'hmm' mean?" I asked.
"I think you have a heart murmur… has anyone ever told you this before?"
"Uh, no. No one's told me that before."
"I see… let me listen again."
Another long pause while she listens.
"Yep, sounds like you have a murmur. Let me tell [Dr GI] so he can have a listen."
We then go on to have a five minute discussion about drugs, psychopharmacology, clinical pharmacy, and people with entitlement issues. (WTF)
My doc comes in, says hello, we talk about a great many things like we always do (last time we talked about the ins and outs of the laws governing anesthesia and CRNAs in the state of Massachusetts and this time we talked about Thanksgiving, travel, and energy efficiency and how it relates to electrical engineering. I love my GI doc — he's great.)
I was substantially less freaked out at this point, and we both almost forgot the murmur. He listens with me sitting up and lying down. He confirms it, suspects PVCs — something I've suspected I've had for about four years now — and we talk cardiologists. Turns out, one of the guys downstairs is an arrhythmia specialist, and does a lot of work with people my age.
–
I've been having mental battles with myself over the last couple of weeks whether I'm merely a hypochondriac, or if there's a real problem with whatever body part is letting me know it's there. I don't like to diagnose myself; I don't like to be one of those people. But I know that 1) I don't like going to the doctor every other week 2) I don't like taking pills and 3) I do my damnest not to be one of the people who taxes the system. I think that sort of rules out hypochondriasis.
Dropping a diagnosis on someone can be very disconcerting, even something relatively benign (most likely) like arrhythmia. Intellectually, I know that heart arrhythmia aren't a huge deal. I know millions of people have some kind of arrhythmia. I also know that most people have PVCs at some point during their life, and that rare is the person who has never had a skipped or extra beat. I have suspected that I have had some kind of heart trouble since the first time I walked up some stairs and I couldn't get my heart rate to drop for about five minutes.
I thought it was just the amphetamines I was taking at the time for ADHD. I'm certain those didn't help.
Since then, I've had four EKGs, and had my heart listened to by four doctors and countless nurses. They've all told me that I'm fine; there's nothing wrong. I heard it so many times, I believed it. I chalked it up to mere anxiety.
I'd just like to tell the world that I'm fucking tired of people ruling out something *actually* being wrong simply because I'm young. Delve deeper. Refer, if you must. Sitting here in my chair, sipping my decaf Columbian, this revelation explains a few things that I noticed were different about myself since since first grade.
I was always a pretty strong long-distance runner, but I suspect that's simply because walking was never (mentally) an option. I DID notice (and other parents noticed) that it took me longer to recover than the other kids. Where I might run a mile in 7 minutes or so, it would take me 45 minutes to an hour to get my breathing under control where other kids would be fine in 10 or 15 minutes.
Being in first grade, I thought nothing of it the first time someone said something to me about it. My chronic ear infections and multiple cases of severe poison ivy tended to be more pressing.
In junior high and early high school, I had a paper route, and despite biking 5-10 miles every day loaded down with newspapers, my CV endurance never really got beyond a certain point. When I played lacrosse in high school, my heart felt like it was going to explode pretty regularly. Moreso than the other kids.
More recently, while at the gym, I've hated cardio. There are days where I can run for 45 minutes to an hour and be fine, except for the very long recovery time afterwards. Other days, as soon as I move past a walk, I can feel my heart skipping beats. If I continue on, I get lightheaded and have to sit down. (Otherwise I'll fall down.) The more regular I am with cardio, the worse this problem is. It doesn't get better, it gets worse. Oh, and there's also the fact that about 10% of the time that I take a deep breath, my heart skips. (This is why deep breathing doesn't work for me when it comes to managing panic attacks.)
Of course, there's nothing wrong with me. I'm too young to have anything wrong with me. 19? 21? 25? Fuck it, it's all in your head. Maybe these R tards should read Groopman's book and try to take some of the principles to heart.
So while I was a little upset today at being informed that I have a heart murmur, I am somewhat comforted to know that I'm not mentally defective (at least not in that way 
), and that perhaps I have an answer. At last. Yes, I know murmurs come and go. They're not always present while the provider is listening. But a Holter monitor was never discussed. Maybe I should have been more pushy. But like I said, I didn't want to be one of those people.
–
Back to diagnosis dropping before I close. Knowing something in your mind and reconciling it with the emotional reaction you have to this input are two completely different animals. In fact, logical reconciliation doesn't come until later, if at all.
I have been guilty of being somewhat dismissive when someone tells me something that's obviously bothering them. If I know it's trivial, or a problem that's easily managed, you tend to not think of it as a terribly big deal. Familiarity with and exposure to a disease state causes a recalibration of Normal. Perhaps even indifference.
But nothing is trivial, even if it's not serious or life-threatening. Not to the person receiving the news. Nothing. (Unless they're drugged out of their mind, like I was when they said "Hey dude you have Crohn's." I just didn't give a fuck at that point.)
Oh, and what takes the cake is that when I got home from work tonight, and informed my family of this revelation, my mom laughs and says "Oh yeah, I have a murmur, too." and my grandmother pipes up and tells me she's got one, too. What the fuck, people. TELL ME THESE THINGS so when I'm asked if there's any history of illness in my family I can give the correct answer. I know my grandfather died of a heart attack, but I always thought he was an isolated case and it was because he was a lifelong smoker and alcoholic. :rolleyes: But no, apparently most of my grandmother's brothers and sisters and my own aunts and uncles have murmurs, too.
The mind boggles. Apparently this information is trivial.
Next up: a visit to the orthopedic surgeon
MY SUPERHERO. LET ME SHOW YOU HIM.
Can't… stop… laughing…
(Ouch, that's gonna hurt.)
[tags]fail, humor[/tags]
How do you handle stepping on someone else's toes?
Two recent posts of mine have dealt with bad information, and both times I've wondered what the accepted protocol is for addressing it. Obviously "Hey dumbass, go read some medical literature," doesn't cut it. I addressed one instance — the cholesterol one — quietly, after it happened. It wasn't life-threatening misinformation, so immediate intervention didn't seem necessary.
I didn't bother to say anything about the antibiotic shenanigans.
The trouble with this is addressing something someone does without stepping on their toes. If I do something stupid, I'd like someone to smack me upside the head and tell me I'm wrong. Pussyfooting around the issue is for people with no self-confidence. I don't have that problem — after all, I write on the Intarweb, and think people actually care about what I have to say, don't I? 
— so just come right out and tell me I'm wrong.*
Not everyone is that resilient, however, and I'm sensitive to this.
Recently I've heard a pharmacist say she was going to take lots of Vitamin C and echinacea to get over a cold. I've seen pharmacists recommend Airborne for cold on more than one occasion. I've heard a pharmacist recommend a homeopathic remedy for migraine. I said nothing — these suggestions aren't harmful, but they certainly aren't helpful, either. In these cases, it's just not worth the effort. Besides, Father Time and the body's own defenses will clear these problems up on their own. (And in the case of the migraine, I suspect it was psychosomatic anyway.)
When someone says something boneheaded to a patient, how do you handle it? Especially if it's a pharmacist colleague? I would imagine doctors and nurses run into this problem from time to time as well, even if they practice alone now.
* I'm happy to say that this hasn't happened in a very long time, which can be viewed as either a good thing (I'm SMRT!) or a bad thing (I work with a bunch of idiots). Which one I lean towards is dependent on where and who I am working with, naturally.
Sometimes I need to talk to the doctor, not the nurse
Most of the time, I don't mind dealing with nurses. Not MAs or CNAs. Real nurses. They're pretty great with very, very few exceptions, and with very rare exception they know and acknowledge their limits. In fact, I've had quite a few laughs on the phone with nurses, and I'm usually relieved when the office staff puts me through to a nurse, because I know I'm not going to get smoke blown up my ass. Anyway, one of the limits of your average RN's knowledge is drugs and pharmacology. Yeah, they might take a PCol class, but it's not real pharmacology. And that's perfectly fine.
But this means that sometimes, just sometimes, talking to a nurse isn't enough. This usually happens when I need to speak to the doctor about a combination of problems. Most recently it was a dosage change coupled with non-compliance, a language barrier, and poor instructions on the script thanks to a pharmacokinetic difference between two drugs in the same class that it was clear the doctor wasn't aware of. (Doubling the dose of a statin with a short half life isn't going to matter if it's taken at the wrong time of day.)
It was for a Medicaid patient, who needs an interpreter who isn't always around to explain things to her. Visions of trainwrecks were dancing through my head at this point. How am I going to get this across to the prescriber, who I know for certain will not come to the phone?
So I call the office, and I get a call back from the nurse about 20 minutes later. I explain the issue as clearly as I can, and I can just feel her eyes glazing over. "Oh. Um. Hmm. Okay. I'm going need to have Dr So-and-so call you back tomorrow."
Argh.
It can take days to unravel a problem like this. It would take 30 seconds if I could just speak to the fucking doctor. I have the solution figured out. Now all I need is for him to listen, and then say "OK".
And they wonder why pharmacists don't do more interventions like this: they just don't have the time to chase some telephobic jackass around all day because he can't ever be bothered to come to the phone. This folks, is why the children's game is called "Telephone". Everyone loses.