Animal Crackers

Last week a pharmaceutical representative came by with lunch. This is a pretty rare event in the ED. Dug reps tend to market newer, more expensive agents, but given the financial resources (or lack thereof) in the majority of our ED patient population, we tend to focus on using older, low-cost generic drugs whenever possible. When we do prescribe medications, it’s most often for an acute condition, and the patient will be on the medication for a limited time only. We rarely prescribe any chronic medications for conditions such as high blood pressure or diabetes, and if we do it’s to refill the patient’s current meds, not to start them on anything new. So most drug reps will cordially wave at us in the hallway while spending their time with physicians who are more likely to use their products. It’s simply good business.

But today’s rep actually had a drug that could be useful in the ED, and Free Lunch Etiquette demanded that I spend at least five minutes hearing about the product. (It would be ten minutes if I got a pen.) Today’s product was a new pain medication, something in between ibuprofen and a narcotic. The rep was very articulate in explaining that the drug influenced both mu-opiod agonist ascending pathways and norepinephrine reuptake inhibitor descending tracts, and I was very dutiful in nodding my head. (Truth be told, I have no idea what these things are. I’ll be looking them up later tonight.) But I did notice that the mascot for this new drug is a lion with a rose in its’ mouth.

Somewhere in between hearing that the drug falls into Pregnancy Category C and that I should not use it with MOA inhibitors because it may cause serotonin syndrome (got all that?), I asked a question.

“Do I get one of those?”

“One of what?”

“A lion. If I use this drug, can I have a lion?”

“You mean like a stuffed lion?”

“No, I mean a lion. You can skip the rose. I want a lion.”

Anyone who knows me would expect this kind of thing. I‘m the guy who orders drinks by color just to see bartenders fall all over themselves trying to figure out what I’m up to. (Although sometimes the bartender gets the better of me. I was with friends at Harry’s in St. Augustine and I asked for something orange. The barman said he could make something called a Big Easy, and I said I didn’t care as long as it was orange. What was delivered to me was a VERY orange drink created on the spot called the Little Difficult.) Plus, I had done this before.

When I first came back to this ED full-time, there was a young drug rep who was marketing a new antibiotic. Their mascot was a tiger, and in the promotional literature you would see a doctor walking down the hallways of a hospital with a tiger by his side. I thought that was very nifty, and so I asked the drug rep if I used the drug, can I get a tiger? The tiger could help scare the bacterial infection into submission, and it could be pretty useful in the ED as well. “You don’t think you can find a ride home tonight? Well, okay. Why don’t you spend the night in this small windowless and locked exam room with my TIGER that I haven’t fed yet today. Oh, and that topical ointment we put on your scalp? It smells like fresh kudu.” The poor drug rep had no idea what to do. She fell back on her training, saying something about the 30s ribosomal unit and in vitro activity and Acinetobacter baumannii and other stuff I still haven’t gotten around to looking up, and I would keep asking if I got a tiger. There’s probably a reason she doesn’t come around anymore.

I explained to the rep that this was a serious request for a therapeutic lion. I thought that, like the drug, he could be a useful adjunct in the mitigation of pain. “You say your pain is unbearable? Let’s try a comparison. Which is worse…your pain, or being bitten by my LION? I will only give you narcotics if your pain is worse than being bitten by my LION. How bad’s that pain now, boss?”

This rep had been in the business for a while. She thought for a moment. “You know, twenty years ago we probably could have arranged that. But with these new marketing restrictions, all I can offer you is a pen that makes a really loud and scary click. Please, help yourself to the lo mein.”