Five Minutes as a Pharmacist

I reach for the basket.

I am no longer human.

The basket is white, meaning the person has likely already been here for at least 30 minutes and is probably getting impatient. I am careful to carry its contents to my miniscule space before emptying it to the counter piece by piece. There are eight bottles inside, four are filled with specific quantities of drugs, the other four are larger stock bottles that threaten to fall over at any moment. I stack the four legal-sized labels together and remove the bottom two thirds, folding the package insert by three before tucking it under the basket for safe keeping. The top third contains all the pertinent information, which I line up carefully so as to reveal the crucial information on the sticker at the top right hand side. I move each stock bottle and dispensing bottle to match each label, as the dance begins.

I see lisinopril first—angiotensen converting enzyme inhibitor. Usual dose between 2.5 and 40mg. Usually dosed once a day. Used for blood pressure control. Particularly useful for kidney protection in diabetic patients. People usually get it in increments of thirty. I verify the National Drug Code (NDC) number with the information on the label to ensure that the proper drug is being dispensed.

The phone begins ringing.

The NDC matches, and I make a mark next to where the technician has written the number and their signature. I open the bottle and look at the pills. They are circular and round, etched with the symbol of the manufacturer. They appear intact, so I close the bottle and make sure it is properly childproofed. I circle the quantity to verify. I turn the labeled bottle in my hand and read the instructions. One time by mouth daily. They are correct.

The phone is still ringing. But now a technician answers.

The second phone begins to ring.

I check for ancillary labels, they are also correct, and not covering any important information. I make my symbol at the top right corner of the labeled bottle, remove the fill sticker and place it on the refill log. I tear off the now empty top part of the remaining label and throw it away. The bottom part serves as a receipt, and I verify the date of birth of the patient.

Someone at the counter is having an argument over whether or not their insurance will cover a three month supply. I may have to intervene.

The second phone is answered.

I place the bottle atop its label and slide it to the side. I now see furosemide—loop diuretic. Usual dose between 10 and 80mg. Usually dosed once a day, but can be dosed multiple times depending on the condition. Can be used for blood pressure, but also conditions involving fluid overload. Particularly useful for patients with congestive heart failure. People usually get a month's supply or more due to the ease of cost. I verify the NDC number on the label to ensure the proper druge is being dispensed.

The first technician on the phone asks me if a person allergic to penicillin will have an allergy to cephalexin. I know cephalexin is a first generation cephalosporin, and that class has a 10% crossover with penicillin allergy. I ask what the nature of the allergy is.

The NDC matches, and I make a mark next to where the technician has written the number and their signature.

The patient doesn't know what it does to them.

I open the bottle and look at the pills that are circular round and white.

I ask if they have ever had it before in their profile. The pills appear intact, so I close the bottle and make sure it is properly childproofed.

The second technician informs me that there is a doctor holding on line 101.

I circle the quantity to verify.

The patient has had cephalexin before in the past. I turn the labeled bottle in my hand and read the instructions. It is one time daily. They are correct.

I tell the technician that it should be okay if they didn't have a reaction before, but to watch out for unusual signs of tingling, swelling, or hives. The technicians tells the patient and the phone goes down.

I pick up the freestanding phone and dial in 101. "Hello, this is a pharmacist." It is Doctor Smith's office wanting to call in a prescription.

I check for ancillary labels and squeeze in another that warns of dizziness or drowsiness. I place the bottle atop its label and slide it to the side.

I go to a computer. "Go ahead," I say as I write down Dr. Smith's name. I get the name of the patient and the spelling—the patient's date of birth. It does not match in our system. I write a note to get it verified. I get the drug, the strength, the instructions for use—the phone next to me begins ringing again—I get the quantity and number of refills. It is a prescription that is already in this patient's profile from another physician. The patient is no longer seeing that physician anymore.

The phone next to me is answered by another technician. I get the name of the person calling and the office phone number and give them my name. Platitudes are exchanged and I hang up.

I walk back to the scripts I am filling. I tear off the empty part of the remaining label and throw it away. I write down the date of birth on the receipt for the cashiers to check and place the bottle atop its label and put it next to the lisinopril prescription.

The phone starts ringing again.

The next one is potassium chloride—also known as KCl, a salt used for electrolye imbalances. Often given when other drugs deplete potassium.

The person at the window is not happy with the answer my technician gave them for why we cannot accept their insurance for 90 days. I am asked to intervene.

I greet the person at the window. They repeat what my technician has said. I confirm it—the insurance did not provide an adequate contract for us to maintain business and dispense a 90 day supply.

The phone begins ringing again.

I ask if he has seen the cash price. He says he has not, so I have the technician give it to them.

Another technician approaches with a printout of a patient's profile for a year. I verify the information and certify it.

The man is pleased with the cash price and buys double. I thank him and return to my scripts.

Potassium chloride, dosed in milliequivalents instead of milligrams. Usually 10 or 20mEq. Can be dosed multiple times, but once a day may be enough. I verify the NDC number with the information on the label—the phone is finally answered after several rings and begins to ring twice in succession—people usually get a month's increment. The NDC matches and I make a mark next to where the technician has written their number and the signature.

A tech informs me that I have two transfers to make from another pharmacy and I have been given 2 hours to do so.

I open the bottle and look at the pills. The pills are oblong and somewhat translucent and are intact. I close the bottle and childproof it, circling the quantity to verify. I turn the labeled bottle in my hand and read the instructions.

The phone is still ringing, but there are only three phones in the pharmacy and all of them are being used so it cannot be answered.

One time by mouth daily. The instructions are sufficient.

I hear someone say that there is not a generic on a drug next to me, and turn to correct them so they can give the patient the correct information.

I check for ancillary labels, which are also correct and not covering any important information. I make my symbol at the top right corner of the labeled bottle, remove the fill sticker, and place it on the refill log.

A phone slams down and a technician calls out for a pharmacist on 102. I put on my earpiece.

I tear off the now empty top part of the remaining label and throw it away. The bottom receipt belongs to the patient and I verify the date of birth.

I put that to the side and press the earpiece to answer. "Hello, this is a pharmacist. What can I do for you?"

I reach for the last drug in the set. It is metformin—biguanide oral antidiabetic agent. Usual dose 500-2550mg in divided doses per day of immediate release or 500 to 2000mg per day of extended release. Can be dosed depending on the daily dose one time or more per day depending on patient need. Used for type II diabetes mellitus, and insulin intolerance secondary to other conditions, Syndrome X, and others. People usually get it in monthly increments or more.

The person on the phone claims she had not had a bowel movement in three days. I ask what their normal bowel movement schedule is.

I verify the NDC number with the information on the label to ensure that the proper drug is being dispensed.

The person usually goes every day, but hasn't gone for three days. I ask if there is anything that changed recently.

The NDC matches and I make a mark next to where the technician has written the number and their signature. I open the bottle and look at the pills.

The patient on the phone has just gotten back from surgery and had to take some heavy duty opioid pain medicines.

The pills are circular and round, etched with the symbol of the manufacturer and appear intact.

I tell the patient that constipation is a common side effect of the medication and does not go away like some of the other side effects of opiates.

I close the bottle and make sure it is properly childproofed and circle the quantity to verify.

The patient says they only have a few days left, but they are getting worried about not having a bowel movement. I ask if they have a hard, distended stomach, or otherwise having stomach pain.

This metformin is a new script so I pick it up to read it. I turn the labeled bottle in my hand and reach the instructions. One pill by mouth six times a day. I check the drug strength again. It is metformin 500mg immediate release. This is an overdose.

The patient on the phone claims to be having no significant stomach problems.

As they explain the details I press mute on my end and walk up to a technician. "Get a nurse from this office on the phone for me." The technician nods and moves to get a phone.

I unmute my phone and ask the patient what other medications they are taking. Other than the opiate, they only take a multivitamin. I ask how much calcium the multivitamin has. The amount is within adequate ranges and should not be contributing much to the constipation.

The phones continue to ring and are answered by technicians.

I suggest using a stool softner, docusate sodium, for the duration of the opiate therapy and suggest starting them out at one pill twice a day.

The technician has managed to get a nurse on the phone and passes me the line.

I ask the patient if there is anything else. They say no and thank me before hanging up.

I pick up the second line and ask the nurse to check the chart for the patient's metformin. The prescription was written in error. It was supposed to be 4 times a day. I make the alteration to the script and put her name down with thanks. We exchange platitudes and hang up.

I pass the script to a technician to have them fix the label. As they print up the label I line up the receipts with the drug names in a row so I can perform higher level checks.

Furosemide and lisinopril are both blood pressure medications and put the patient at risk for orthostasis. Furosemide is potassium depleting, and lisinopril can cause elevated potassium. This could even out, but is unlikely since furosemide is so strong. So the potassium was added later in therapy as verified by the date above.

The phone rings again.

Someone at the counter has not been here before and is presenting controlled scripts. The technician asks if they need to be verified. I say yes.

The potassium will replace losses from the furosemide, but the physician and the patient will need to be vigilant for signs of hyper or hypokalemia, which can be life threatening. The metformin label returns and I mark it up and replace the bottle label with the proper instructions after verifying it. The metformin should be controlling the blood glucose, but asking the patient will only reveal that. If this is a diabetic patient, then the lisinopril is appropriate because of its renal protective effect. Aggressive blood pressure therapy is also indicated. I check their profile and note that they are taking a statin drug for cholesterol, so there is no need to be concerned about that. The lisinopril carries the peculiar side effect of cough, so the patient will need to be asked about this as well as warned to alert the physician if there is any unusual swelling that could indicate angioedema.

The patient at the window decides to take their scripts elsewhere because the hour wait is too long.

The phones continue to ring and are answered by technicians.

Though rare, lactic acidosis is possible with metformin, and since this is a new script for the patient, I choose to place a counseling sticker on the first label to have a chance to talk with them about how to properly use their medicine. It will also allow me to give them the warnings from the other medications and their interactions.

One of the cashiers is looking for a prescription and calls out a name. I remain silent, indicating that I do not have it, but notice it next to me and point that out as next.

Satisfied that the prescription is ready for the patient, I retrieve a bag from the counter and open it. I stuff in the four medications, not forgetting the package insert tucked under the basket for them to read. I staple the receipts to the top of the bag carefully so they will remain when the HIPPA sticker is removed and the counseling notice is pointed face up. I toss the bag into the basket behind me.

I become human long enough to look at the stack next to me. One prescription done, 249 to go.

The phone begins to ring again.

I reach for another basket.

I am no longer human.