The importance of holistic recommendations as part of a patient’s treatment approach

An emergency physician calls the pharmacy wanting to speak with the pharmacist. My staff ask which patient it is regarding and if there is anything they can help with. The Dr gives a patient name that the staff do not see on file, and proceed to tell him this. He says he wants to discuss a case that he is sending over to us, someone new to town. I take the line.“Samier speaking—the pharmacist, how can I help you?” “Hey Samier, it is Fernando, Dr. X, from emerg. at the hospital. Listen, I have a case of a 67-y.o. Chinese male who presented to emerg. with severe acute cough and fever and chills, accompanied by his wife. He does not speak a lick of English, but his wife can get by. We don’t have translation services for their dialect nor can I find it on Google translate. I told his wife to come to you to fill the script for Paxlovid that I wrote him. Symptoms started four days ago. His CXR showed ground glass opacities consistent with COVID lung infection, positive on PCR. Here is my cell. Please call me when they come so I can ensure that he starts treatment. Let me know if you have any questions. I don’t usually prescribe Paxlovid.”I tell my staff the situation so that when the specified patient appears, they can grab me so that I can speak with them directly in the office—and ensure they are wearing masks and that we sanitize right after they leave. One hour later, the patient’s wife presents, and I introduce myself. Of course, the script states: “Paxlovid, dispense 1 tab BID x 5 days,” with no other info. Luckily, I had already looked up and asked the emerg doc for the patient’s renal function and list of other meds (assuming he wouldn’t have written it on the rx, and to save me time). I also confirm by asking patient’s wife about the medication list. She reports NKDA, no other meds. I adjust the prescription to state: “take 3 tabs (2 pink and 1 white tab) by mouth twice daily for 5 days.” The wife started explaining to me that her husband is very reluctant to take any meds. Culturally speaking, he has felt very healthy up until this point, hence his being 67 with no meds. He didn’t even want to go to emergency for this Covid infection, but his wife forced him. She says he may not even want to start taking this medication, he may wait to fight it off on his own. She is making direct eye contact with me the entire time, with tears in her eyes, obviously worried about whether he’ll make it or not— he’s been quite week and not eating much, but able to walk and talk. She says he’s very stubborn. When I asked about COVID vaccination status, she immediately disconnects her sharp eye contact, as if in shame, and states that he is unvaccinated by choice, but she is fully vaccinated. I explain the power of Paxlovid: how it’ll help reduce the risk of the virus from dividing in his body, and prevent the infection from transitioning from a viral infection to an inflammatory infection which could potentially overwhelm his lungs, resulting in hospitalization, intubation or even death. Odds are against him given his age over 60, and the lack of a vaccination to help boost his immune system against the virus. I explain that it is imperative that the patient start the Paxlovid ASAP, and it absolutely must be within 5 days of symptom onset. Today being day 4, “waiting it out” is not advisable. I also gave her OTC Tylenol, Advil, Omnaris nasal spray and dextromethorphan, as she insisted on symptomatic treatments. I also gave her an oximeter. I told her that although it is expensive, it is important that she keep the device on his finger at all times, especially at night, and if it ever drops below 90, she is to call 9-1-1 or take him to emergency ASAP. I called the emergency doc explaining the above. He is very appreciative and relieved.Read: Most federal supply of Paxlovid will expire on March 31, Ontario, B.C. tell pharmacistsTwo days go by and she presents again to pharmacy, wearing a mask, but in tears, wanting to speak with me. (It’s fascinating how much the eyes can tell about how an individual is feeling on the inside; they truly are the gates to the heart.) She is heartbroken, and thinks her husband is dying. Coughing is worse, he is now not eating. She wants a recommendation for an OTC meal supplement (e.g. Boost or Ensure), and asks if there is anything else I can do. I ask about his O2 stats, and she states it’s at 90, and he refuses to go back to emergency. I ask the wife if she thinks the patient loves her, to which she said of course. So Itell her, go home and tell your husband if you really love me and want to still be with me, you have to listen to me and you must go to emergency. When I asked the wife if she knew why he didn’t like going to the hospital, she said “he gets overwhelmed with the wait, seeing a different person every time, and not being treated well because of the language barrier, so he gets frustrated and would rather deal with it on his own. He’s always been independent.” I tell his wife, go home and tell him I will contact the emergency doc to try and expedite the process. But just go to emergency ASAP. This can be life threatening and it sounds like he may have a superimposed bacterial infection on top of the COVID infection. She agrees, motions to give me a hug, but understands the reason why I refused, given the exposure risk. I step back a little, pull down my mask, and state “I will do everything I can to help you. Do not worry, you are doing the right thing. Just take him to emergency, and you can spend time with him until he is better, promise?” I then Google translate ‘thank you’ in Chinese, to which she smiles behind her tears, and leaves.I phone the emergency doc on the number he gave me. He answers within one ring, and asks if everything is OK. I explain the above situation, and ask if he can take care of them upon their arrival. He states his shift will start in a couple of hours, so will be on the lookout. I give him a verbal hand over of the patient’s current situation so when they present to emergency, triage will understand the severity. The next day, the ER doc texts me saying they came. “Thank you for referring them, repeat CXR showed pneumonia. He’s been admitted for fluids + antibiotics + continuation of Paxlovid.A week later, the wife comes to the pharmacy, again with a mask, and in tears. But this time they are joyful tears— you can tell the difference based on the way the outer corner of the eyes are tightened, and the glow in the centre of the eyes. I sighed with relief. She thanked me and the emergency doc for working together. Her husband has been discharged and feels so much better after antibiotics, fluids, and rest in hospital.Lessons to learn from this case:As pharmacists, yes we are drug therapy experts, but it does not mean we focus JUST on drugs. we focus on disease prevention, identification, and treatment. Within treatment there is cure, treatment, symptom relief and symptom monitoring. Couple your recommendations with non- drug options that can be complimentary and equally important as the treatment itself.Collaboration, collaboration, collaboration. Inter-professional collaboration among different clinicians will ALWAYS lead to improved, enhanced and optimized patient care. If you disagree, re-check the oath you took in your respective university professional education. Our oath to benevolence and non-maleficence implies doing anything we can to optimize the patient care journey and outcome, which involves maximizing your resources and utilizing your fellow colleagues’ expertiseI always say, the most influential clinician is not just the one who has the most information and knowledge, but the one that also knows the patient the most. If the patient is not on board, it doesn’t matter how brilliant you are, as they won’t listen to you. If you have rapport with the patient, all else will follow.

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The importance of holistic recommendations as part of a patient’s treatment approach

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Samier Kamar

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