It takes only thirty minutes to make betamethasone the right way.
Heidi Medeiros should know. She's made it enough times. One Friday last May, while working at Doc's Pharmacy in Walnut Creek, the 31-year-old pharmacy technician received what seemed like her umpteenth request for a batch of the anti-inflammatory drug, phoned in by doctors from the nearby Sierra Surgery Center. The drug's manufacturer, Schering-Plough Inc., had halted its production that February after the US Food and Drug Administration raised some manufacturing concerns, and local shortages were keeping Medeiros and her colleagues busy.
By that time, Medeiros knew the recipe by heart. She'd gotten her start as a clerk in a Thrifty pharmacy fresh out of high school, and later completed the company's free training program to become a pharmacy technician. Despite the new title, she spent most of her time "counting and pushing, counting and pushing" endless streams of prescription pills. Over the next five years, the young woman got married, had two kids, and in 1997 landed a job at Doc's, where she got to do the really fun stuff drug compounding.
Only one percent of the nation's pharmacies still formulates medications on-site, and Doc's was Northern California's most prolific drug compounder. Competition from drugstore chains and pharmaceutical manufacturers have made it tough for mom 'n' pop compounders to survive in a world where customers prefer their pills by the truckload. But at Doc's, Medeiros enjoyed the pleasures of scratching out custom medicines for patients who needed a tweak on the standard two aspirins in the morning. For kids, she extracted the bitter taste out of penicillin and added cherry flavoring; she learned how to take the burn out of skin creams and make soothing gels for cancer patients, and to modify prescriptions for patients with deadly allergies.
She also learned how to whip up medications for hospitals in a pinch. After the shortage began, Medeiros found herself making betamethasone every week. She'd picked up most of her skills from watching Doc's owner Bob Horwitz, a nationally renowned compounder. Horwitz was so adamant about his craft "the art and science of compounding," he called it that he gladly taught anyone who was willing to learn. That included his young techs, whom the law allows to formulate medications so long as they are closely supervised by a licensed pharmacist.
Last May 11, Medeiros walked to the back of the store, pulled the ten ingredients for betamethasone from the shelves, and spread out her provisions beneath a sterile laminar hood. For this blend, sterility was crucial. Medeiros was making an injectable suspension that would be pumped directly into the patient's bloodstream. "I was always careful and clean with everything I did," she recalls. "And I always said, 'If I wouldn't take the drug myself, then I wouldn't let anyone else take it.' That was my standard."
Medeiros made 300 milliliters of the milky suspension, enough to fill a grande-sized Starbucks coffee cup. The next step called for sterilizing the drug in an autoclave, but Doc's didn't own one. So, as she had done dozens of times before, Medeiros carried the jar to the outpatient clinic next door and made a neighborly deal with the receptionist: For the price of a Coke, she could use the autoclave.
After about fifteen minutes, the betamethasone jar was so hot that Medeiros needed a towel to protect her skin. Goods in hand, she returned to Doc's, where she divided the drug into three sterile 100-milliliter jars, labeled her work, cleaned her workstation, and then, she says, headed straight home to begin a weeklong vacation as a cook at her daughter's summer camp.
Within twelve days of her return, two people who'd been injected with the betamethasone were already dead.
George Stahl was a veteran UPS driver, six-foot-four and built, but over the years the job had worked him. The 47-year-old, whose pals affectionately called him "Pinhead," had his first surgery in 1994 when doctors fused his lower spine, then again the next year to add more hardware to fix the first surgery. A few years later, his back was still hurting like hell, and the surgeon decided to pull all the metal out, leaving George with his original fusion. Still the pain shot down his long legs and up into his stomach, and he still couldn't bend over. Returning to work seemed a distant dream.
At the suggestion of a pain-management therapist, the deliveryman went to see an orthopedic surgeon, Dr. Joseph Narloch, who prescribed a series of three betamethasone shots. The first shot was heaven. George's rigid back loosened like he was a boy. He couldn't wait for the next one. His wife, Marilyn Scully, drove him to the second appointment and again, George left reinvigorated. "If I can feel like this for a year," he told her, "then maybe I can get back to work."
Marilyn wasn't available to drive her husband to the Sierra Surgery Center on May 29 for his third shot. She worked, and he'd signed up for a two o'clock slot. But a neighbor offered to shuttle George there and back.
The couple had a daily ritual. Normally, when Marilyn returned from work sometime between 6:30 and 7 p.m., George would come out to greet her in the kitchen. "On that day," Marilyn says, "he wasn't there." Instead, she heard her husband calling from the bedroom, "Marilyn! Marilyn! This is it, Marilyn! This is it!" George came stalking down the hallway, wearing only gym shorts, gripping his head in his massive hands. He was screaming, which wasn't like George at all.
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