Solace

So I'm on rotations right now.  Fourth year!!  I didn't think I would make it.  I was very close to failing the last semester of therapy due to my inability to learn antimicrobials and their appropriate regimens.

So of course I'm about to finish up an Antimicrobial Stewardship rotation.

Things have been rather...general the first 3.5 weeks of the rotation.  Then last Wednesday a patient came in with large leg swelling and turning purple/black.  They were in sepsis.  They had cut themselves on Sunday and had gotten a prescription for Keflex.  However, the cut had progressed into an infection.  By the time they had gotten to the hospital we threw Primaxin, Zyvox, clindamycin, and Levaquin at them, due to the quick progression.  The discoloration and swelling had moved up toward the hip area.

We couldn't transfer them to a different hospital, one more equipped for this type of issue.  So we arranged for an amputation, which was successful, but unfortunately the patient was in such poor condition that they passed away.  The surgeon said that the leg had pockets of fluid and gas that smelled horrible, and that the muscle had turned into mush.  It was also possible that the gangrene had progressed to the lower back region.

It shook everyone up in the pharmacy and Infectious Disease department, especially since the patient passed away within 24 hours of arrival to the hospital.  I've thought about that patient every day.

The cultures came back with Proteus vulgaris, Klebsiella, and Aeromonas.  Aeromonas loves to live in water and is a rather sensitive microbe, but specific in what you can treat it with.  I've found that Bactrim, 3rd and 4th generation cephalosporins, and the quinolones are effective in treating it.  Antibiotics that are commonly prescribed in the healthcare community.

Anyway, another patient, this time a 10 year old came in on Monday with the same presentation.  The culture came back today (Wednesday) positive for Aeromonas.  I hope it all works out, and I will definitely check on their progress.

It was by good happenstance that the Infectious Disease physician was alerted to the patient and recognized the similar progression and ordered the culture, as well as started them on appropriate antibiotics.

I like to think that the previous patient would be somewhat glad that their infection last week was able to alert us to potentially save a 10 year old.  I'll probably continue to think about these cases for a long time to come.

My love/hate relationship with February...

Filling prescriptions in March is slightly more simple than at any other time during the year because figuring out when controlled refills are due is just so darn easy.

My pharmacy refills controlled medications 2 days before the patient should be completely out.

Therefore, if they received a 30 day supply the month before, we will refill it on the 28th day.  February usually has 28 days, so the day that you filled in February is the day that you will fill in March.  It's pretty awesome that way.

However, I got into an argument with a patient today about refilling their medication.  Our computer will allow the prescription to go through 3 days early, so we have to be careful.  Even then, it was still too soon to fill today, as this would have been 4 days early.

Anyways, the Rx was filled on 2/24 and we "always fill 2 days before it was filled last month" and that "every time they call someone else has a different rule."  Couldn't get it through their head.  Tried.  Failed.  Frustrated.  I don't doubt if they will try to get it earlier each month.

However, if you're getting 2 days early each month, but the end of the year you will have 24 extra days of medication.  That's almost an entire month.  Where are they all going?