My General Registration has finally arrived

I’ve finally received my General Registration as a pharmacist today. I lodged my application since November 8th, it finally arrived on December 31st.

During these 9 weeks, I’ve gone through excitement, annoyance, frustration ,out rage and indifference. I’ve called AHPRA at least 10 times, and by the end I’ve come to accept the thought that ‘it’s not going to happen any time soon’.

It wasn’t until my friend texted me that I realise the registration came through. Too bad that it had to come through the day after my last shift. I guess I'll get to experience being a full pharmacist at my next job.

Oh well, now it’s time to look for a job next year! It’s really scary… hope it all goes well!

Happy New Year People!

Waiting for general registration

Back in November 6th I've submitted my registration paperworks to AHPRA (Australian Health Practitioner Registration Agency) to change my registration from a provisional pharmacist to a general pharmacist.

Their website indicates that the process from provisional to general takes up to 10 days, but can also be between 4-6 weeks.

It has now been 6 weeks and I'm still waiting for news. I must admit that this has driven me crazy, especially when I see my friends obtain their general registration even though they submitted their application later than I did.

Oh well, I've called them up at lease 10 times over the last month or so. I don't think there is any more I can do. I think this is a test of my patience, and I am failing miserably.

Probably the moment I stop caring and checking my application progress, they'll give me the good news.

FORXIGA - Completely new class of diabetes medicine

AstraZeneca are releasing a new drug called Forxiga (for-zee-ga) or dapagliflozin (da-pa-glee-flo-sin). It is marketed as a medicine to treat type 2 diabetes. The difference that sets this medicine apart from current diabetes medicines is that it it's mechanism is insulin-independent.

While current diabetes medicines either augment insulin production, increase insulin sensitivity or supplement insulin directly into the body, this completely new class of diabetes medicine does not rely on the insulin pathway.

How it works:

Dapagliflozin works in the kidneys. It stops glucose from being re-absorbed and thus increasing glucose elimination. In short, it makes your urine sweet.

MOA of Forxiga

Side effects:

1. As the glucose content of the urine increases, so does the patient's chances of getting a UTI. Patient's are likely to get UTIs or other infections within 1 week of treatment. However studies showed that 1 course of appropriate treatment successfully eliminate the infection without future recurrence. However, be cautious in patients already having recurring UTIs.
2. Dapagliflozin's effect is completely renally dependant. Monitor renal function and be careful in patients with CrCl less than 60ml/min.
3. It can cause weight loss. Although unproven, the theory is that it increases sodium excretion that leads to accompanied loss of water.
   

Role in therapy: 

Dapagliflozin is designed to be used in combination with
current diabetes medicines. However not recommended with pioglitazone. 

Dosage:

10mg tablet once daily. No dose adjustments required for any demographic. One dose fits all.

When will it come out?

December 1st 2013. It will be on the PBS, but will require an Authority.

Personal comment:

Exciting and novel mechanism to treat diabetes. This opens up a new option for patients that have problems with their insulin. I'm looking forward to seeing it in practice.

I got into med school!

After peeping at my phone throughout work the whole day I finally received the email I was waiting for!

ANU has offered me a CSP position. 

I am so happy and grateful of the outcome. Just like Oscar winners I want to thank everybody that has helped me through this journey! My friends and family that cheered me along the way, my boss who allowed me to take time off for the interview, my girlfriend who prepared me every step of the way etc.

Now that I'm here, it is officially time to look for next year's accommodations! Bye bye Brisbane, and hello Canberra!

Waiting for news

Apparently today is the day med offers are being released.

According to Catherine from GEMSAS, all rejection emails have been sent out.

As I sit here email-less, I think it means good news.

Oh lunch break.

Ah! I see an email!... and it's a false alarm.

Transition from provisional to general registration

So far I am at the stage of transitioning from my provisional pharmacist registration to general registration.

Requirements to become a pharmacists are as follows:

• Complete an Intern Training Portfolio (from either Guild, PSA or UQ)
• Pass the Intern Written Exam
• Pass the Intern Oral exam 
• Complete 1824 hours of supervised practice.

I have already completed the first two requirements. I'll find out my oral exam results on the 4th Nov and my 1824 hours should tick on the 7th of November. 

According to the Australian Health Practitioner Regulation Agency (AHPRA), I could apply for general registration now because my provisional license is expiring at the end of November and I am expected to finish all requirements within the next 60 days. 

So I followed the online form and paid $477 ($160 application fee and $317 registration fee) to get my general registration. Once I paid for the application, I was sent a check list of supporting documents to send the registration agency to complete the paperwork. I have 60 days to lodge my supporting documents. If all goes well, I'll be sending them on their way on the 11th of November once I've completed all four criteria and got my paperwork certified. 

5 days left!

Assuming the medicine offers to be released on Nov 1st, there is only 5 days left!

My self-confidence has been constantly fluctuating for the past few weeks. Oscillating between 'I did awesome' to 'Something must have gone wrong'. In other words, I'd like to think that I'd definitely get in but another part of my self is telling me that I am being too cocky. **Stupid brain, pick a side and stay that way!!**

At this stage I have finished all necessary assessments, so I have some extra time to myself. It is really tempting to look up potential rental options for next year, but both my girlfriend and my other conscience would slap me on the wrist and tell me 'it's too early to look!'

WELL... it's only 5 days left!

Kenacomb vs Otodex

When treating ear infections, doctors commonly prescribe either kenacomb or otodex.

Recently there has been a shortage of otodex from suppliers, I have been told it won't be back until December. Today I have had to make phone calls to local doctors to ask them to substitute their otodex scripts to kenacomb.

What is the difference between the two products?

Both products are corticosteroids with anti-infective ingredients, and are both indicated to treat otitis externa.

The difference lies between the ingredients.

Kenacomb:

• Corticosteroid: Triamcinolone 0.1%
• Antibiotic: Neomycin 0.25%
• Antibiotic: Gramicidin 0.025%
• Anti-fungal: Nystatin 100 000 units/mL

     Dose: 3 drops 2-3 times a day.


Otodex:

• Corticosteroid: Dexamethasone 0.05%
• Antibiotic: Framycetin 0.5% 
• Antibiotic: Gramicidin 0.005%

     Dose: 3 drops 3-4 times a day

Voi la, similar but different. Confusing to remember either way.

Wind pain

Part of my job is to help patient's with their medical problems. I am to help identify minor ailments and provide appropriate treatment. This saves GPs from needing to deal with simple headaches, sprains, diarrhoea, constipation cases.

Today a lady approached me and told me she had 'wind pain'. What the hell is wind pain? When I asked her what the symptoms felt like, she told me she doesn't have diarrhoea, constipation but just stomach aches from gas buildup. I guess she meant she felt bloated. I could not identify what was causing this, and she told me the pain was severe and debilitating. She has tried products such as buscopan and degas, with no success. Well... there goes the products I would have recommended. I suggested for her to take general pain killers for the time being and book an appointment with a doctor to further investigate the issue.

When the patient was on her way I thought to myself "Gees... wind pain, where on earth did she come by such a term?"

30 mins before my oral

This is the last assessment for the year!
In 3 hours I will be done!

2 days from my final oral exam and 4 weeks from med offer results

Only going up,with no end it sight.

All aboard the tension roller coaster! Tension is only going to go up!

Preparing for my intern oral exam

Shortly after finishing my med school interviews, I'm now onto my next project: intern oral exam.

For those who aren't familiar, for an intern pharmacist there are 4 main hurdles to pass before you get registered.

After the interview: Approaching the end of a chapter.

Yesterday I had my interview at ANU for medicine. The journey was quite the roller coaster ride. I have been through joy, despair, periods of confidence and times of nerve wracking self doubt.

Thinking about it, the process of getting into medicine for me has been like a marathon race. It began from GAMSAT preparation in January, sitting the GAMSAT in March, receiving GAMSAT results in May, applying for med school via GEMSAS (the next day), receiving offers for interviews in August, preparing for interviews and attending the interview in September.

Osteoporosis, available treatment and ONJ

What is osteoporosis?

Osteoporosis is a systemic condition characterized by low bone mass and deterioration of the microarchitecture of the bone. This can lead to bone fragility and the increase risk of fractures.

Figure 1 Comparing the microarchitecture of bone in normal vs osteoporosis patients.

Preparing for my ANU interviews (Work)

My first med school interview at the Australian National University (ANU) is coming up in a few weeks on the 24th September.

I've already taken time off work, booked my plane ticket and my accommodation. I'm ready to go and impress some strangers!

Wrapping up my first patient

In the pharmacy today I was called out to help dress the wounds of a patient. The patient was an gentleman in his 60s who fell over in his garden whilst gardening. He landed on a brick and grazed his forearm.

A prickly situation

While at work today, my colleague took in a bag full of used diabetes needle tips from a patient. He didn't bring them in a yellow sharps bin, instead put them into a brown paper bag. Whilst my colleague was putting the tips into our large needle bin, a needle broke through the bag and pricked her finger.

An unexpected reading

While at work today, a pharmacy assistant calls me to assist a gentleman. She tells me that he brought in a blood glucose machine and seems to have problems with it.

The gentleman has not been using his monitor for a few months, and wanted me to have a look at it to see if it was still working fine. As he did a test, instead of displaying a reading, his meter prompted: "HIGH KETONES".

Hmm...

As I looked through his previous test results (done earlier this morning) I see that his readings were 27.8mmol/L! As a reference, blood glucose readings above 10mmol/L could be counted as uncontrolled. This patient was OFF THE CHARTS!

After asking the patient about his diabetes medications, I find that he has not been taking his medications for a while. He was constantly experiencing dryness in his mouth, and has also been going frequently to the bathroom. I guess those were signs that his body was telling him his diabetes was out of control.

I tried to reinforce to the patient the importance to see his doctor and get it under control. However the patient had his excuses and reasons why he didn't take his medication and why he doesn't want to see the doctor yet.

While it is my job to look out for the patient's well being, there is only so much I can do other than give him suggestions.

In the end, the patient went on with his daily life. I doubt he would have gone to see his doctor.

August 29th

Med school interviews come out tomorrow! (I think...?)

Hope it comes with good news!


Update:
ANU med school has given me an interview opportunity!
Yey?

I'm both stoked and shocked. Stoked because last year I got nothing. Shocked because I was expecting Melbourne or Griffith!

The importance of sunscreen

             

As we live in the Sunshine State (Queensland, Australia), it is important to be aware of the dangers of the sun and how to protect our skin from it.

The sun gives us a lot of things: warmth, light and life. However the sun can also give us skin cancers, premature aging and sun burns when we expose our bare skins too long underneath its glorious rays.

A measure of courage

What would you do if you see a person bleeding from the head walk towards you? Would you call out to him to offer him help? Or would you avoid him and walk on by.

What if this person had been beaten half to death by an angry gang, and you find out they are hunting him to finish the job. Would you still try to help him?

I believe our choices in these situations define who we are. Our decisions are made in a split-second as we encounter the situation. I would have chose to walk on by and pretend nothing happened. This makes me a coward. However when my brother told me he stayed to help the man, I was really proud of him.

Last night on his way home, my brother encountered a man bleeding profusely from the head. As the man walked towards him, he could see that half of the man's face was swollen. My brother decided to stop and help the man straight away. After enquiring about the situation, he found out that the guy was beaten up because he taunted a group of New Zealanders. He managed to get away, but they were still trying to find him and beat him up some more.

Although the guy may have been an ass, he still needed medical attention. My brother called an ambulance and waited with the guy for it to come. While they were waiting, he saw the gang walk down the street. He hid the guy behind a tree, and mislead the gang in a different direction. 

As the ambulance did not come after 20 minutes, he called a cab and took him to the hospital himself. He then walked himself home after leaving the guy in the emergency ward. 

From this situation, my brother demonstrated tremendous courage and compassion. I think he went beyond his duty to care for the person. I admire how he handled the situation, and I am proud to be his brother.  

Vets, doctors and pharmacists

My best friend is vet student in his final year. It is interesting to hear him talk about his field of expertise, work stories and surgical cases. I find it refreshing as the stories he tells are still within the realm of medicines, however completely foreign from the pharmacy setting.

Listening to his anecdotes I feel that vet students are pretty much the same as medical students. They both need to learn pathophysiology of disease, diagnostics, and also the medicines to treat. They both have too much to learn, never enough time to do so thus leading to practically no social time left over. None the less, we try to make time to catch up and talk about random things.

One thing I learnt from him was that cats cannot tolerate paracetamol. This is because they lack an enzyme causing toxic metabolites of paracetamol to build up in their body!

Tadalafil, Cialis and Adcirca

Part of my daily routine is to unpack medicines that we ordered in, and one particular special order caught my eye.

This medicine cost around about $900 to order from the supplier. 

Initially I did not recognise the brand Adcirca, however the generic name of Tadalafil certainly rang a bell.

As you may have guessed, Tadalafil is the generic name for Cialis: a popular medication used for erectile disfunction. 

Although the active ingredient and tablet strength for both Cialis and Adcirca is the same, the indication for the tablets are completely different. 

Cialis is marketed for erectile disfunctions, while Adcirca is marketed for pulmonary hypertension. 

Pulmonary hypertension is a condition where there is a build up of pressure in the pulmonary circulation. A common cause for it is in left ventricular heart failure. This is because the heart is lacking the ability to pump blood efficiently causing a buildup of blood in the lungs. 

The mechanism of action for tadalafil in pulmonary hypertension is to relax the smooth muscle in the pulmonary vascular bed producing vasodilation and reduction in pulmonary vascular resistance. 

The dosage is twice daily which explains the large box of 56 tablets.

Another difference between Cialis and Adcirca is the price. 

Cialis is considered a recreational medication that is not essential to keep a person alive. This means that Cialis is not covered by the PBS scheme and thus patients need to pay for the full price. Cialis usually comes in a box of 4 tablets or 8 tablets (10mg, 20mg strength) and could cost between $80-$160. 

On the other hand, as Adcirca helps manage a patient's disease state, it is covered by the PBS scheme. This means that eligible patients to the PBS criteria only need to pay either $36.10 or $5.90 for this medication. I feel quite amazed considering that the patient gets 56 tablets (vs 8 tablets) for only a fraction of the price.

I wonder if the patients on Adcirca get the benefits of Cialis. It is the same active ingredient at the same strength. I hope side effects such as priapism would not be a side effect...

Adenine and Thymine

A-T, G-C. The building blocks of our DNA.

While watching Vsauce, I came across an A-T base pair necklace. I joked with my girlfriend "Hey, that pair matches our initials! It would be cute if we got a set."

Here I am a few weeks later, $90 short but with a pair of Adenine and Thymine necklaces. 

It may be nerdy, but I'm happy!

You should check it out:

http://store.madewithmolecules.com/product/dna-rna-base-pair-friendship-necklaces

Dealing with the unknown

From a customer's point of view, I am expected to have knowledge of the products I sell. The unfortunate truth is that there are things I do not know or have just forgot. Ever since working in the pharmacy as a student, I have been challenged to counsel patients on products that I am unfamiliar with.

After years of practice, I have developed a set of techniques to wing my way through a counseling session without looking unprofessional.

1) Buy yourself some time:

For example,

Me: Good morning Madame, here is your medication. Have you used this product before?

Patient: nope.

Me: Okay! Well let me get you a print out.

(Now quickly leave the patient and go behind the counter to print out a consumer medicine information leaflet)

Once you have bought yourself some time, 

2) download as much information into your brain while the leaflet is being printed.

Quickly consult your usual resources such as the CMI, AMH, eMIMS etc to get the vital information.

Info such as:

what the medicine is 

What it is used for

How it works (not crucial)

How to take the medicine.

What to look out for on the medicine

Side effects

3) regurgitate the information to the patient, without looking like you are regurgitating

For example:

Me: thank you for waiting Madame.

So I've got your information leaflet right here. 

So, this mediation is commonly used for ( insert indication)

Is this what you are using it for?

Ok good, so has the doctor told you how to take the medicine?

Yep, that is correct, he instructs you to (read the label)

As all medicines have side effects, with this medicine you may need to watch out for (read 1-2 common side effects)

As this is your first time taking this medicine, I would like you to watch out for ( insert symptoms to watch out for or other crucial information)

Do you have a follow up appointment with the doctor?

That's good! I hope the medicine works well for you!

If you have any problems, do not hesitate to give us a call or come back. We are more than happy to help you!

Have a nice day!

-----------------------------------

Each unfamiliar product I counseled has been a learning opportunity. 

Now that I'm 7 months into my internship, I'm happy to say I at least know a bit about most products I see each day. 

I still come across products I've never heard of before, but hey, I've got a long way to go!

Our professional boundaries

One of my Webster pack patients has been ill. Her daughter tells us that she is constantly nauseous, and on occasion will vomit back up a dose of medications once she takes them.

This can be a problem as she misses out on her daily dose, so the daughter is asking us to give them extra tablets. This way when she vomits, the daughter will have spare tablets to give her accordingly.

Our pharmacy decided to supply her with a whole weeks worth of medications packed into a Webster pack. Later on, we received a call from the doctor's surgery. The nurse had found out on what we did for the patient, and was upset with our actions.

She said that we have no way of knowing how much the drug was absorbed when the patient vomits them up, thus it is dangerous to give the patient extra medicine to take. For all we know, they could be double dosing. She said we over stepped our boundary as a pharmacist and made a therapeutic decision without contacting the doctor. 

Reflecting on this case, this has been a learning experience for me. Firstly it taught me to be aware of the professional boundaries as a pharmacist. I have become more cautious when giving advice /making decisions ever since. 

Secondly, I do not agree with what the nurse said. As a pharmacist if it is impossible for us to know how much a drug was absorbed, how on earth would the doctor be able to know? As for Webster packing services, we keep patients medications to put them into packs. This is not a staged supply of medicines. We are not locking away the patients medicines, but more or less keeping them in the pharmacy for our convenience. The patient has every right to ask for their own medicine. If the tablets were at home with the daughter, she would have given them to the mother without letting us know. 

Indeed it is hard to judge how much the drug has been absorbed, but we had no reason not to give her extra tablets. 

As I said before, what I've learnt from this case is not that we did the wrong thing, but to be more considerate of the doctor's role. If I come across a similar situation, I would give the doctor a call ask for their opinion. I bet they would have made the same decision too.

********

Recently, this patient has passed away. I hope she is in a better place and is no longer suffering. Thank you very much for the learning experience.

Complications with our PBS system

Australia's Pharmaceutical Benefits Scheme (PBS) is a wonderful system where the government pays for the cost of medicines for the its people. All Australians who own a medicare card are entitled to the PBS scheme, and essentially patients do not need to pay more than $36.10 for medications no matter if the medicine's actual price costs hundreds or thousands of dollars. Concession patients pay up to a maximum of $5.90 per item, and the rest is paid by our government. 

Although there are people who complain they pay a lot for their medicines, I suspect they do not know the actual savings they are making with this generous subsidy from PBS scheme. 

An additional feature of the PBS system is called the Safety Net. The safety net ensures further subsidy to patients who spend more than a certain amount on medicines in a calendar year. For general patients, the safety net amount is $1,390.xx. Once they have spent more than that amount, the pharmacy will issue them a Concession safety net card which entitles them to have scripts that cost no more than $5.90 for the rest of the year. For concession patients whom pay $5.90 for scripts, once they reach 60 scripts in a year, the pharmacy issues an Entitlement safety net card. This allows them to receive any additional medications for FREE* for the rest of the year.

*Additional out-of-pocket charges may apply to certain medications, but anywhoo.

It is part of a pharmacist's daily job to dispense medications and issue out safety net cards to those who have reached the requirements. For customers who stick with one particular store, life for the pharmacist would be quite easy. The dispensing software would prompt the pharmacist to issue a card, and then it would print out a list of all the medicines that the patient paid for within the calendar year. We would then get the patient to sign the print out, take out a safety net card with a specific code, register it with the associated paper work (by writing the card number onto the print out) and then issuing the card to the patient. 

Once the pharmacist has collected 12 or more of these paper works, he/she then sends of the paperwork to medicare to officially activate the issued safety net cards.

To make life more complicated for a pharmacist, patients are not legally bound to go to only one pharmacy. As pharmacies do not share dispensing information with each other, it makes it difficult for the system to keep track of when the patient reaches safety net. To over come this problem, medicare has safety net record forms available for patients. This record form is a sticker collector that allows pharmacists to stick specific stickers onto the form as physical evidence of the purchase of medication. This allows patients to go from pharmacy to pharmacy and still reach safety net without missing out on their entitlement. 

Curse you Record Form! As fun as a sticker board sounds, after 6 - 7 months of collecting stickers, it becomes a messy, dirty, floppy board of peeling stickers that we need to sort through to ensure the patient checks out. The night mare begins when the pharmacist has to add up 74 slimy stickers worth of medicines to make sure the total adds up to $1390!!  

I am positive that in our current day and age, we are way past using hard copies to operate the safety net system. We lack a overlaying system that would unify all pharmacy dispensing data. With current cloud technology, I believe this is certainly possible to achieve, however impossible to implement. If the government is having trouble implementing a unified system for doctors, I doubt the safey net would see any differences in the near future.

Sigh... back to counting stickers

45, 46, 47 .... what number was I up to again? Darn it!

 

Why you should not sell drugs.

 This is the story I heard from my friend's colleague. From this information, I cannot ensure how credible it is, but the message it sends is valid none the less.

The is the story of a pharmacist who decided to steal Fentanyl patches from the store she worked at and sold them illegally to customers without prescriptions. For those who don't know, fentanyl is an opioid analgesic, and like all opioid medicines have an addictive potential. Patients who become dependent on opioids will experience withdraw symptoms when they don't have the drug in their system, and on occasion exhibit drug seeking behavior to get hold of the medication. As of such, the government schedules these medicines as Controlled Drugs (S8 medicines), and require them to be locked up in a safe when stored in a pharmacy. The regulations to how these medicines can be obtained is a lot stricter compared to regular medicines.  Combining the strict regulations to obtain the medicine legally and the nature of this medicine, it is plain to see that there is a market for selling this medicine illegally. 

In order to make some extra money on the side, the pharmacist was selling the medication illegally to patients without a prescription. Unfortunately, the person she sold a fentanyl patch to had passed away from drug over dose. I have not heard what happened to the pharmacist, but I am sure she is in a lot of trouble. 

Putting obvious legal and ethical reasons aside to why we shouldn't break the law and sell controlled medicines illicitly. Selling S8 medicines would have its economical perks. Compared to the official dispensing price of $5.90 for 25 temazepam tablets, I have heard that on the street can go up to hundreds of dollars per tablet. Surely if these tablets are this lucrative, us pharmacists must be selling the product wrongly if we only charge patients $5.90 a box!

It is understandable why this pharmacist took the risk of selling the patches. But judging from the outcome, it does not seem worth the risk. How much money would she have made from selling fentanyl patches? $100 a patch? $200 a patch? Selling 10 of them would get you $2000 dollars. I do not think she would have made more than $15,000 on the side, however she has ended up killing a patient. 

From what I feel, she would now have her license revoked, and possible face a jail sentence. Was this all worth the $15,000?

I don't know how she feels at the moment, but I feel my freedom is worth more than just $15,000.

Difference between a PS Vita and an iPhone

I'm considering to buy a PS Vita. However while looking at the console in the shop it occurred to me that when it comes to gaming, there is a subtle difference between playing with a game on your phone versus a game on your console.

During lunch breaks, I would feel more comfortable to play a game on my phone rather than on a gaming console. Something is telling me that the console would make me look more "into" gaming and thus a more intense gamer?

Call me old-fashioned but I don't think it is appropriate to bring your "Gameboy" to work. Something just doesn't feel right for me to play a PS Vita at work. However, games on the phone do not seem to trigger this feeling. Smart phones are now such a common item that for a grown-up to kill some time on his phone with "Cut the Rope" would not be an uncommon sight.

Ok.... I guess I'll hold off from buying one for now... back to Plants vs Zombies 2

My first post

After graduating university for 7 months, I'm finally getting used to the routine of working as an intern pharmacist.

Every day I would travel to work, clock on and begin my daily ritual.

I would unpack the order, dispense medications, counsell the patients, refill the CONSIS (dispensing robot) and alongside other miscellaneous tasks.

After doing this routine for 7 months, I did not think I have learnt anything new since graduating. However it wasn't until our pharmacy took in a 4th year pharmacy placement student did I realise that how far I've come since I was in her place one year ago.

I would like to use this blog as a place for me to share what I learn, and as a reminder for me to see how far I would go!