Doggtyred
En-Route
Ok gang.. Most who have followed me know I'm an inactive pilot, a career healthcare guy (paramedic, nurse and any day now will be a nurse practitioner) and a pretty regular contributor.
One of the things that is required of me as a nurse in my particular institution is an annual Tuberculin test (aka PPD), a screening test for tuberculosis. They take dead TB proteins, stick it under your skin and if you get a raised bump/rash (of specific minimum size and characteristics) at the site you are considered to have been exposed to TB at some point.
After twenty years of this business , I won the lottery. I had a positive PPD skin test. Could have been exposed at work.. could have been in NP school clinicals.. hell, could have been in public (albeit rare possibility)..,, its spread by close personal contact… not casual fleeting contact…
Now.. I've studied this stuff in the past and taken care of TB patients before and knew I didn't have much to actually worry about. I have a strong immune system. My follow on chest X-ray was negative for any signs of active disease, so I am considered to have LTBI… latent tuberculosis infection. I can go my whole life without ever having a problem, but IF I become immunosuppresed (go on chemo, have major illness, end up on certain medications if I develop rheumatoid arthritis…etc) then it COULD go from a latent to an active infection.
So.. even thought TB is a very slow growing bug, and I'm completely without symptoms, having only been found on an annual scheduled screening, I did my homework, went to the CDC website and pulled up the options for treatment. Typically, treatment for LTBI (IF you even opt for treatment) has traditionally been 9 months of twice weekly INH (Isoniazid) or 4 months of daily Rifampin. Both drugs have the potential for nasty side effects, including liver problems, and one must abstain from alcohol for the duration of treatment.
I looked and saw a new option, INH and a rifampin derivative called Rifapentene that is a once weekly 12 week course of medication that has recent literature affirming its non-inferiorority (i.e. just as good) compared to
traditional courses of meds. Its intended for Directly Observed Therapy, once a week. I then used my Sanford Antibiotic Guide (a medical resource I used in NP school, and will use moving forward) and determined the proper doses to seek. This option is relatively new, with published evidence just coming out in the past few years...
When I went to my primary doc, I went armed with the proper CDC websites pulled up on the iPad, a copy of my chest X-ray image on a disk, a copy of the radiologists report, and my return-to-work form. The doc encouraged me to explore treatment options, review side effects and decide if I did actually want to treat this presumed latent TB infection, and understand the risks involved. Explained that I had done so, and was opting to treat. She then offered the standard regimens. At this point I told her I had noticed a new regimen on the CDC website, and provided my tablet for her to peruse.
She quickly validated it with Up To Date, (which is one of THE best medical reference sites I've ever used, but its a costly one…. but its also available with short term pricing to the general public too, if you ever need it) and within a few minutes we'd worked out that I would do 12 weeks of once a week dosing, my baseline lab work was already on file from previous appointments, we talked about side effects that could indicate a chemical/drug induced hepatitis… and we both agreed that I did not need to present to her office for formal "directly observed therapy" where someone in her office watches me swallow my meds… Chapter 1 complete….
On to chapter 2…
The INH script was sent over electronically from the office. I was given a paper script for the Rifapentene. This clued me in that there might be a problem with getting the Rifapentene, that it might need to be special ordered, or something would pop up. Went to the pharmacy and dropped off the paper script. After a few minutes in the drive through window, the tech came back and said that they "had it generic" and could dispense "today"… I decided to get it "tomorrow" (I'm writing this several days later) and get my regular home meds all at the same time when they were ready for pickup…
…… something didn't sound right and so I asked her what the name of the generic was…. (because Rifapentene IS the generic name) and she told me the med was Mycobutin (which is actually a brand name)…
I drove off from the drive through and wasn't a few yards down the road when I flipped a U-turn, googled Mycobutin, and saw that while its in the same class as the desired med, its NOT Rifapentene. I then went to the walk up counter and asked to speak with the pharmacist…directly.. to clarify just what was going on. While mycobutin is in the same class and might be safe and possibly even just as effective, the regimen that I researched, sought out, obtained a prescription for was called out for by CDC, had been researched and validated. I was not going off label for something like this. If it was an authorized automatic substitution I wanted to know what the basis and evidence was for it, and could I get the ordered med without substitution….
Turns out the pharmacist had looked up the med by starting to type it, and when the generic name for the mycobutin pulled up he clicked it (few letters difference from what was desired, and the mycobutin was in stock, the desired med was not…. so… he zeroed in on the "close enough" med and selected it)… We got things sorted out, he found the right drug, he got it ordered, and its now in hand. And oh.. by the way… searching today and looking at dosing recommendations, the dosage they were about to provide of the WRONG drug was going to be 3 times the daily dose limit of what the WRONG drug should be. (900 mg versus 300 mg recommended max daily dose)
So.. not only did I avoid a med error (Wrong med)… I also avoided an overdose (wrong dose of wrong med)… And had I not done my homework, this would have been a single point of failure (the pharmacist).
Own your medical. You don't have to be a doctor or a nurse or a med student. But understand what medications do. Understand what they do to you, and understand what the safe doses of them are.
One of the things that is required of me as a nurse in my particular institution is an annual Tuberculin test (aka PPD), a screening test for tuberculosis. They take dead TB proteins, stick it under your skin and if you get a raised bump/rash (of specific minimum size and characteristics) at the site you are considered to have been exposed to TB at some point.
After twenty years of this business , I won the lottery. I had a positive PPD skin test. Could have been exposed at work.. could have been in NP school clinicals.. hell, could have been in public (albeit rare possibility)..,, its spread by close personal contact… not casual fleeting contact…
Now.. I've studied this stuff in the past and taken care of TB patients before and knew I didn't have much to actually worry about. I have a strong immune system. My follow on chest X-ray was negative for any signs of active disease, so I am considered to have LTBI… latent tuberculosis infection. I can go my whole life without ever having a problem, but IF I become immunosuppresed (go on chemo, have major illness, end up on certain medications if I develop rheumatoid arthritis…etc) then it COULD go from a latent to an active infection.
So.. even thought TB is a very slow growing bug, and I'm completely without symptoms, having only been found on an annual scheduled screening, I did my homework, went to the CDC website and pulled up the options for treatment. Typically, treatment for LTBI (IF you even opt for treatment) has traditionally been 9 months of twice weekly INH (Isoniazid) or 4 months of daily Rifampin. Both drugs have the potential for nasty side effects, including liver problems, and one must abstain from alcohol for the duration of treatment.
I looked and saw a new option, INH and a rifampin derivative called Rifapentene that is a once weekly 12 week course of medication that has recent literature affirming its non-inferiorority (i.e. just as good) compared to
traditional courses of meds. Its intended for Directly Observed Therapy, once a week. I then used my Sanford Antibiotic Guide (a medical resource I used in NP school, and will use moving forward) and determined the proper doses to seek. This option is relatively new, with published evidence just coming out in the past few years...
When I went to my primary doc, I went armed with the proper CDC websites pulled up on the iPad, a copy of my chest X-ray image on a disk, a copy of the radiologists report, and my return-to-work form. The doc encouraged me to explore treatment options, review side effects and decide if I did actually want to treat this presumed latent TB infection, and understand the risks involved. Explained that I had done so, and was opting to treat. She then offered the standard regimens. At this point I told her I had noticed a new regimen on the CDC website, and provided my tablet for her to peruse.
She quickly validated it with Up To Date, (which is one of THE best medical reference sites I've ever used, but its a costly one…. but its also available with short term pricing to the general public too, if you ever need it) and within a few minutes we'd worked out that I would do 12 weeks of once a week dosing, my baseline lab work was already on file from previous appointments, we talked about side effects that could indicate a chemical/drug induced hepatitis… and we both agreed that I did not need to present to her office for formal "directly observed therapy" where someone in her office watches me swallow my meds… Chapter 1 complete….
On to chapter 2…
The INH script was sent over electronically from the office. I was given a paper script for the Rifapentene. This clued me in that there might be a problem with getting the Rifapentene, that it might need to be special ordered, or something would pop up. Went to the pharmacy and dropped off the paper script. After a few minutes in the drive through window, the tech came back and said that they "had it generic" and could dispense "today"… I decided to get it "tomorrow" (I'm writing this several days later) and get my regular home meds all at the same time when they were ready for pickup…
…… something didn't sound right and so I asked her what the name of the generic was…. (because Rifapentene IS the generic name) and she told me the med was Mycobutin (which is actually a brand name)…
I drove off from the drive through and wasn't a few yards down the road when I flipped a U-turn, googled Mycobutin, and saw that while its in the same class as the desired med, its NOT Rifapentene. I then went to the walk up counter and asked to speak with the pharmacist…directly.. to clarify just what was going on. While mycobutin is in the same class and might be safe and possibly even just as effective, the regimen that I researched, sought out, obtained a prescription for was called out for by CDC, had been researched and validated. I was not going off label for something like this. If it was an authorized automatic substitution I wanted to know what the basis and evidence was for it, and could I get the ordered med without substitution….
Turns out the pharmacist had looked up the med by starting to type it, and when the generic name for the mycobutin pulled up he clicked it (few letters difference from what was desired, and the mycobutin was in stock, the desired med was not…. so… he zeroed in on the "close enough" med and selected it)… We got things sorted out, he found the right drug, he got it ordered, and its now in hand. And oh.. by the way… searching today and looking at dosing recommendations, the dosage they were about to provide of the WRONG drug was going to be 3 times the daily dose limit of what the WRONG drug should be. (900 mg versus 300 mg recommended max daily dose)
So.. not only did I avoid a med error (Wrong med)… I also avoided an overdose (wrong dose of wrong med)… And had I not done my homework, this would have been a single point of failure (the pharmacist).
Own your medical. You don't have to be a doctor or a nurse or a med student. But understand what medications do. Understand what they do to you, and understand what the safe doses of them are.
While the vast majority I know, and I know a lot, are wonderful and humble but there are always a few PhDs who never let you forget there are letters after their name.
