I gave the mother a marked syringe and wrote instructions for her to refrigerate the liquid and give 3 mL mixed into a small amount of fruit juice by mouth twice a day for the usual 5-day course.

To be unqualified, you must be honest

The patient’s mother and I had a mega-documented conversation in which I explained I was not a compounding pharmacist, and that there were no guarantees that this medication would be as safe or effective as the official suspension, although I believed the potential benefits greatly outweighed the risks. I still gave her a prescription for the suspension with instructions to switch to the “real thing” if she ever found a pharmacy that carried it.

I also documented that the parent was reliable and attentive, understood my instructions, and that the child had good daytime supervision while the mother was at work in case she appeared to be getting worse.

The universe hates you

Anti-karma is part of our lives as emergency physicians; good deeds that are even a little unconventional attract the attention of a baleful cosmic eye that seeks to punish us with misfortune, humiliation, and policy guideline meetings. The only defense is confessing to people who know more than you do.

Whenever you compound a medication for a late-night emergency, talk to your pharmacy department the next day. In this particular case, our pharmacist confirmed that the oseltamivir suspension I had created was likely to be stable and effective, but because he knew we had a severe supply problem he went further: he compounded an additional supply to keep in the department as “first dose” treatments and found an independent local pharmacist who would compound suspension during regular business hours.

This way we could give a first dose in the department and prescribe the rest of the suspension, and we could actually suggest a pharmacy that was willing to make it.

Influenza is big this year, and death is still not selling well, so remember; it’s one thing to write down what the patient should do, it’s another thing to make sure they can do it.

Oozers

Much like a hideous winter crocus, anterior epistaxis has a season. The convergence of cold winter air, upper respiratory infections, and dry heat blasting into tiny apartments make friable nasal mucosa even more delicate. And spontaneous anterior bleeds are common. The very mild and very severe cases are straightforward to treat: simple pressure and perhaps a little cautery for mild anterior epistaxis, and packing with ENT involvement for the severe bleeds (and admission if necessary).

“But what if I bleed to death one drop at a time?!”

Then there are “the oozers.” These are patients who are profoundly troubled by the janitorial nature of bleeding that has mostly improved with pressure and cautery alone. They are in little danger, but they often return a few hours after discharge furiously jabbing at a rare, languid droplet of blood with wads of toilet paper. Some of these patients are so anxious that they simply will not tolerate an anterior packing balloon without entering a state of enthusiastic agitation.