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‘It should be the function of medicine to help people die young as late in life as possible.’

September 16, 2008

 
 

Once a week I find myself gazing at a piece of paper neatly divided into four: Customer care,

Sales promotion,

Increasing Professional Knowledge and

Team Work.

We need to search our brains for the most relevant experience we’ve had in the past week and write it down in the most effective way that shows both your decreasing ineptitude and your increasing awareness of how life should be in Boots. This week, while I was writing about my project (of which I shall speak later in this post), the chief pharmacist came into the canteen where I was sitting opposite my tutor.   

‘Come and have a look at this…’ so we both walked out to the store floor, with myself removing my coat along the way (the canteen was chilly).   Än older lady was standing there, looking both amused and apologetic.

    ‘She said she wouldn’t mind telling you what happened. Go on, please.’

   The lady’s eyes looked as if she’d just gone through a bout with Mike Tyson. They were bruised, red and shiny all around the ocular orbit and the presence of a yellowish scabby area near one eye clued us into the fact that this was an unusual infection. 

‘I fell about a week ago’, said the woman and pointed to a cut on her forehead. Compared to the eyes, the cut seemed fairly minor, with a little bruising around it, ‘and afterwards this happened’- here she indicated the eye below the cut- ‘ so I went to the doctor and he put me on antibiotics.’

   

I suddenly realized I’d seen her the previous week, but she had been wearing sunglasses then, with only the bruising on one eye showing a little.  

‘Yesterday, though, the other eye seemed to get infected as well.’ Her hand swept across to the other eye. ‘So I went back to the doctor and he prescribed stronger antibiotics.’

 

I’d never seen anything like that before and neither had the pharmacists. It was an unusually aggressive infection. I only wish I’d had a look at the Rx to see what she was prescribed but after talking to my doctor brothers, it sounds like it may have been a staph. Aureus infection and was most likely treated by flucloxacillin. I’ll check when I go back on Monday. 

 

This case provided me with an interesting link between pharmacology, microbiology and clinical training- as I said in a previous post, it’s one thing to learn about something in a lecture and another entirely to see it for yourself and how it affects the patient who has to deal with it on a daily basis. 

Another patient came in  and asked me if I was the pharmacist. ‘No’, I said, ‘but I’m a pharmacy student. I may be able to help you.’

 

Whereupon she immediately removed her shoe and sock. I indicated a chair nearby and with her in a more comfortable area, I saw what I immediately suspected to be a rampant case of athlete’s foot.  

It was itchy, she hadn’t been having any other symptoms and was not taking any other medication. She seemed to have rather sweaty feet and I was fairly sure it was athlete’s foot and was about to give her some Daktarin (miconazole), when I asked her if she’d like to double check with the pharmacist. 

The pharmacist confirmed my suspicion of athlete’s foot when suddenly the patient mentioned she was pregnant. Well, she was in her early months and not showing just yet. Micanazole, though, is not suitable in pregnancy, so she was given Desenex (zinc undecylate) ointment instead.  

After that I asked everyone if they were pregnant and realized I had abandoned common sense when I asked a 70 year old man if he was pregnant. Fortunately he took it in good humour! In my defence, it had been a long day and it was nearly 9pm…. 

We dispense birth control every day. It’s not something I would take myself- not just because of  the moral issues revolving around it, but also because it causes so many side effects.  I talked about it with my friends and side effects range from severe constipation to acne to unusually large mood swings.  If you stand back and look at it objectively, anything that disturbs your hormonal system, a delicate balance at the best of times, must have several  knock on effects, many of which we’re still finding out about.  The side effects, though, seem to be taken almost for granted by many of the women taking it.  

While insisting they want to continue on their birth control and not try, for example, natural methods of birth control, such as natural family planning.  (NFP, based on careful observation of your menstrual cycle and its effects on your body together with a knowledge of how the menstrual cycle works in coordination with your fertility), they come in asking for curatives for the side effects they experience. 

Ä case like this came in- a young lady had severe acne on her face that extended down the sides of her neck. While talking to her, the pharmacist found out she was on the pill and suggested she come off it. She refused and there was nothing much we could do for her, except recommend , for example, La Roche-Posay Effeklar K which may help the symptoms but not the cause.  It’s cases like that that make it frustrating to know that there is a perfectly good method of birth control that is more in tune with women’s bodies, but the information is not spread enough, or people just don’t want to take the time to understand that certain days of the month they can’t get pregnant and find out which days these are.  The birth control pharmaceutical companies are making great proceeds from this lack of information.  This issue is something I’d like to address eventually.  

I’ll give you one more case study for this week, then I’m off to Dublin to take some exams that I had to miss due to keratitis in June- ofloxacin and cyclopentolate eye drops cleared that up a treat- so next week I’ll only have three days- Monday, Friday and Saturday- until my Boots Summer Placement comes to an end! 

I was standing at the dispensary, perusing the BNF, when a customer came up brandishing Clarityn and asking whether she could pay for it there. I moved over to the tills and was about to ring it through, when I asked if she’d taken this before.  She said yes, but something felt wrong- she wasn’t displaying  the usual allergic symptoms that people usually have when they’re buying antihistamines.  I asked her what she was taking it for. She pointed to the area under her eyes and said she felt blocked up there. I asked her if she also felt blocked over her eyes. She said she was and she had no other symptoms, except a generally blocked feeling behind the eyes/nose- it was fairly indicative of blocked sinuses, so I told her  I thought she’d be better off taking Actifed or Sudafed instead— she walked off with a medication that far better suited her symptoms. The lesson I took away from this particular experience is that people do NOT  always know what they have, and if they do, what they pick to treat it isn’t always what the need. That’s why we exist- pharmacy students who will eventually become pharmacists, experts on medicines, their effects on the human body and how to give ‘the right drug, to the right person, in the right dosage, at the right time.’ 

    In the IPU recently I read that a pharmacist in Achill installed an automatic dispensary machine and the responses to that, amongst the pharmacists and the pharmacy students I know, were mixed. Some bemoaned the loss of another function of pharmacists, whereas others welcomed the change over to a more clinically-based role in health care.  For my part, I feel that this offers both positives and negatives. People are far more likely to go to their pharmacist first than their GP, especially those who dislike going to the doctor (myself included, I’m afraid) , those who think the doctor is too expensive and those who just want something treated with the minimum of hassle will all go to the pharmacist first. Pharmacists are front line healthcare professionals who have the knowledge and experience needed to know when something can be treated simply or whether a referral is needed.

Local pharmacies also have the happy benefit of seeing regular customers and thus are far more likely to be able to keep tabs on their progress and  how they’re coping with their medication, with side effects, detioration and compliance.   You will see the patient more often than the doctor many times,  filling repeats, and have the chance to see firsthand how effective many medicines are, whereas oftentimes a doctor may see the patient once, fill a script and not see the patient until a repeat prescription is needed or symptoms worsen sufficiently to require another visit.  

    On the other hand—when the line between pharmacists and GPs blur even more, it creates more tension between the two professions which, while working in tandem, are having to constantly redefine the professional lines of territory. They do have the corner on diagnosing, but is our position all as secure as we hope it is? The profession of pharmacy has changed an awful lot from the days when compounding was the primary focus (the Celt pub in Talbot St. in Dublin is a lovely old pub that used to be a pharmacy- you can see all the drug drawers with the old labels on them.) to one that balanced out compounding together with an almost excessive knowledge of each drug and its properties, to one that exists today. It’s no wonder the profession is in a state of flux at the moment with constant shifts on every border and the proportion of final year students finding a pre-reg place down to 40%. It’s worrying, but rather than worrying, we should welcome this as a chance to redefine ourselves the way we want to. After all, few doctors have been trained much in the area of herbal and natural medicines, whereas we take pharmacognosy much more seriously. The area of phytochemistry is still firmly within our territory and I think we should make the most of this. 

   It’s a fascinating field and with each plant containing several phytochemicals and with thousands of phytochemicals in current knowledge, with many more still not understood or known of, it has a long way to go in research and development.  As pharmacists, we can broach this area, tying together our knowledge of pharmacology both of ‘straight’ drugs (AKA synthetic drugs) and the far more chemically complex botanic medicine.   

So that’s the tack I’m taking and I’m curious to see how this goes. I’m looking forward to seeing the developments that take place both in this area and in the general arena of pharmacy as a profession in its entirety. 

I’ve covered an awful lot in this post- I hope you made it through to the end! If you did, congratulations. I’ll see you next week for my last post! 
 

Disclaimer: All the opinions expressed in this post are my own and not that of Boots the Chemist or the School of Pharmacy in Trinity College Dublin.

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