Time for Research and Adventure!

Today finishes off my ER rotation, and just in the nick of time with the Olympics around the corner.  This last week has been great. Yesterday I gave my case presentation on the role of alteplase in cardiac arrest and massive pulmonary embolism, so look for that on here soon, as well as my nebulized fentanyl presentation from last week. Other interventions I got to make this week involved:
1) The usual med rec for most ER patients
2) Adjusting vancomycin doses for a patient with severe renal failure (the patient was close to death with a DNR order, but somehow came around and is now hemodynamically stable and his infection is improving)
3) Ensured a patient with acute stroke had an appropriate prn antihypertensive (labetalol was ordered but the patient was getting bradycardic, so I called the doctor and we added hydralazine)
4) Saw another procedural sedation for a 6 year old boy with a broken and dislocated elbow (it was nostalgic for me since I had the same injury in Grade 12, minus the fracture)
The last month has flown by, and it has been a very enjoyable experience. My only beef with working as an emergency pharmacist is that you don’t get to do much counselling, since you’re seeing patients only on admittance, and not on discharge. Otherwise, I found working in the ER very enjoyable.
Now I am going to get 2 week of project time, to hopefully recruit the last 5 patients I need, and start building some pharmacokinetic models. Then I will be heading to Colorado for a week of snowboarding, where I will get to experience the wonders of Vail and Keystone resorts. I will also get to play around on the Landing Pad, a great creation by two of my best friends. Anyone with an interest in snow sports and injury prevention shoudl check them out: www.katalinnovations.com.

Cheers!

Emergency, continued

I am now 2.5 weeks into my 4-week ER rotation at Lion’s Gate, and time has flown by. Pharmacy practice in the Emergency Department is unlike all the other rotations I’ve done. This is because you often see patients only very briefly, you have to work them up quickly, and if you’re lucky you get to make a few interventions. Unfortunately, you often find big problems with your patients, and you only get to write your note and hope that the next pharmacist or doctor on the ward the patient goes to will see your advice. Case and point, a patient I saw today:

-83 year old female admitted with SOB, cough, fever… CAP, patient put on Pip/Tazo and Vanco. PMH significant for Asthma, COPD, RA, OP, HTN, prev. MRSA, and chronic C Diff.  I was able to dose-adjust the Pip/Tazo and Vancomycin for her renal function, and ensure a Vanco trough level was ordered, as well as straighen out her puffers for her respiratory conditions. However, this patient had been receiving CHRONIC ORAL VANCOMYCIN therapy for roughly the last 4 years!! Even with chronic C Diff, the most vanco recommended is a 5 week tapering regimen.  Furthermore, she only had 1 positive C Diff culture in the last 4 years. C Diff diarrhea is defined by a response to metro or vanco therapy, and this patient had not been responding. She also was told by her doctor that it was ok to take loperamide, which is also strongly advised against when a patient has C Diff.  I wrote my note in the chart and also wrote a memo to the Hospitalist strongly advising that the patient required a GI consult.  She is now gone from the ER, and I can only hope things will get sorted out for her.

Otherwise, things continue on in the ER… I continue to work up multiple patients everyday, and get as much done as I can before they get transferred or discharged. I am getting more comfortable with digging for the appropriate information, such as calling the patient’s son/daughter for complete histories, search the old charts, and looking on Care Connect for lab values from the community.

I have also been able to have therapeutic discussions about treating Status Epilepticus, and Acute Stroke in the last week. Tomorrow I give my presentation on nebulized fentanyl vs. iv morphine to the ER nurses and physicians, which will hopefully spark some interest in performing a trial.

Fast Times at Lion’s Gate ED

I woke up this morning and realized I was almost halfway through my second week of my Emerg rotation already! Time sure flies when you’re on the run.  Being a pharmacist in the Emergency Department is unlike most wards, because you have an extremely high patient turnover rate, and so you have to tailor your practice accordingly.  In my experience so far, it seems to me the ED pharmacist’s main roles are:

1) Troubleshooting immediate problems the patient is facing with appropriate interventions

2) Medication Reconciliation, either with immediate interventions or a passover to the clinical pharmacist on the ward the patient ends up at

3) Preparing a primary workup for the practitioners that assume care of the patient once he/she leaves the ED

I am now roughly 3/8 of the way through my rotation, and I am enjoying the interventions I have been able to make so far. I get to document my work on every patient I assess, either through a patient workup that goes in the chart, or a simple memo to the doctor (or sometimes both).  For instance, today I had a patient being treated for pneumonia who was receiving DVT prophylaxis with heparin 5000u sc q12h.  An appropriate dose, but this patient had a history of a hemorrhagic stroke about 9 months ago, and so I wrote a note to the doctor bringing up this issue, and he promptly d/c’d the heparin.  Here are some other things I have been able to do in the last week and a half:

1) Work up patients and make monitoring and therapeutic recommendations with such problems as CHF exacerbation, ACS, pneumonia, GI bleeds, abdominal pain, delirium, dizziness/nausea, and neutropenia

2) Therapeutic discussion about Advanced Cardiac Life Support (ACLS) – the day before the discussion I saw a patient come in with cardiac arrest, who soon died after roughly 1.5 hours of ACLS.

3) Therapeutic discussion about Rapid Sequence Intubation (RSI) and Procedural Sedation and Analgesia (PSA) – right after the discussion I got to see PSA firsthand as the physician reset a patients’ broken wrist… after she received the ketamin and propofol, of course.

Later this week I am giving a presentation to ED nurses and physicians about a study comparing nebulized fentanyl to iv morphine in pediatric patients with suspected limb fractures… based on the talk, plans may evolve to perform our own study on this topic. I have also run into a couple juicy topics that might turn into a case presentation, such as:

1) Optimal dosing method for alteplase in patients in cardiac arrest secondary to a massive pulmonary embolism 

2) The evidence behind DVT prophylaxis in patients with a history of hemorrhagic stroke.

Holiday Wrap-Up

Hopefully everyone had a Merry Christmas and a Happy New Year; I was able to get back home to Regina for Christmas, and then ring in the new year up in Whistler.  Unfortunately, I came down with a cold, so my snowboarding was cut short, but not before I finished my AST-1 Avalanche Safety course.  It’s a must-have for anyone interested in getting out in the backcountry, where ski patrollers aren’t doing avalanche control.

I also was able to set up a Flickr account over the holidays, so feel free to check that out: http://www.flickr.com/photos/45909201@N06/

Next week I start a month-long rotation at Lion’s Gate Hospital working in the ER with Susanne Moadebi. I am hoping to build on the efficiency of my patient work-up skills, since I know the ER has a high patient turnover rate.  This will also be my first time working at LGH, so I am hoping to get accustomed to the hospital and it’s computer systems rather quickly, so that I can focus on the clinical work.

ICU Wrap-Up, Midyear and IV Turkey Dinner

Whoops, I totally missed an ICU update from my last week, so this post has a little catching up to do.

I finished my ICU rotation on Dec. 4 with a solid week, building confidence in my patient workups and giving myICU Case presentation on my last day. My case presentation was about carbapenem use in seizure disorders, and an interaction between meropenem and valproic acid. I plan to set up a separate tab on this site for my case presentations, so look for that soon.

I then took off to Vegas for a week for the ASHP Midyear Conference. They normally say, “What happens in Vegas, stays in Vegas”, however that may not be the case (over the holidays I plan to set up a Flickr account, so pictures will be put up there). The conference was amazing to see… 20,000 pharmacists, and all kinds of exhibits from drug companies, free dinners, etc. etc. Oh yes, and informative lectures too.

After Vegas, I came back, grabbed a quick day of snowboarding in at Mt. Seymour, and then started my TPN rotation at St. Paul’s, with fellow resident Jenny Anderson and our preceptor, Greg Head. Hence the dorky title (I keep imagining a Christmas dinner given in a TPN). This was a very informative week, and working with Greg and Jenny has been great. I feel I learned a great deal about parenteral nutrition, including its indications, how to calculate a patient’s nutrient requirements, and individual patient physiological characteristics that need to be considered when addressing particular nutrients.

I now to get to finish up my last afternoon of my TPN rotation, and then take Christmas holidays, which will involve travelling home to Regina, some project work, some snowboarding, and a lot of relaxation, before I start my ER rotation at Lion’s Gate in January.

ICU almost nicely through

I thought that title had a nice ring to it…

Monday to Friday of this week has been like night and day for me.  After realizing I needed to pick up the pace in my clinical patient workups, I re-vamped my systematic approach and since then I have gone from feeling totally lost to finally finding a comfort zone in the ICU. As well, Gabe and I have had many discussions of the big ICU literature, mainly this week around activated Protein C and Corticosteroids in sepsis, and next week we will be talking about glycemic control and DVT and stress ulcer prophylaxis in the ICU setting.

In the last week, I have grown more comfortable in working up patients and making recommendations. These are some of the interventions I have been able to make and things I have been able to observe:

1) Many interventions involving antibiotic dosages based on renal function

2) Changing antibiotics (antibiotic stewardship) based on cultures and sensitivities as they came in

3)  Re-starting PTA medications based on medication reconciliation after patients have recovered from septic shock

4) Watched a CVC line insertion this afternoon on an intubated 

5) Watched a patient get intubated as they arrived to the ICU

6) Contributed to the tailoring of sedative medications as patients stabilize and require less sedation

and the clincher….

7) Watched surgeons remove what looked like a twig from a patient’s urethra

Next week is my last week, and it is chock-full with therapeutic discussions with Gabe, Academic Halfday on Wednesday, and my case presentation on Friday.

ICU Learning Curve

I am now 2 weeks deep in my ICU rotation, and I have learned a great deal in that time… probably by the time I finish my rotation, I will finally start feeling comfortable treating this kind of population!  The medications used in this population, and the acuity and complexity of the patients on this ward is quite intimidating, but Gabe has been a great preceptor, and I am easing my way into it. My routine for the last 2 weeks has been the following: I get in around 7:30, and work up my patients until about 9, when we start X-Ray rounds.  X-Ray rounds have been quite interesting, and I have learned how to recognize some parts of thoracic pathology on X-Rays, such as pleural effusions, atelactasis, and consolidations.  We then go on medical rounds with the team, which usually goes from 10-2.  Rounds are great, because I learn a lot of interesting things about medical pathophysiology.  After rounds, I grab a quick lunch, and then my afternoons usually consist of catching up on patient issues, and/or a therapeutic discussion.  I have had therapeutic discussions with Gabe about acute respiratory failure, pain, anxiety, delirium and sedation, and arterial blood gases.  I also had a discussion with Kate, the ICU dietician, today about nutrition and the different feeding routes and supplements (ie. Isosource, Resource, Novasource Renal) that are commonly used in the ICU.  I was also able to do a Journal Club discussion on a recent study from the Netherlands about digestive tract decontamination in the ICU.  And today, I found a patient case for my case presentation which I will be presenting in 2 weeks time.

The last 2 weeks have been daunting, but very rewarding, and I am hoping that the next 2 weeks will be even more educational and rewarding.

Long Time No See, but Now ICU!

So, it’s been a while. A lot has happened in the last two weeks, so I’ll divvy it up as follows:

1) Two weeks ago I did a 1-week stint at DPIC doing Toxicology with Dr. Debra Kent. I was also working with fellow residents Jenny Anderson, Andrew Joaquin, Amy Sauerwein, and Tony Kiang. This was a great week that was very informative. I came into the rotation hoping to learn a bit about the management of the more common overdoses, such as ASA and acetaminophen, and also to get a feel for the empiric approach to a poisoned patient. I came out getting exactly what I was hoping and a bit more as well. Debra was very easy-going, which made the rotation very relaxed, and she was extremely knowledgeable so it was a pleasure to learn from her.

2) This past week I was working on my project. I had a patient booked for every day of the week, so my days were all booked from 7-9am.  Other than that, I had plans to try and recruit some more patients, as well as learn a bit about how to assemble my pharmacokinetic models using the program WinNonLin.  Basically, I wasn’t sure how I was going to fill up my time… well, that was unnecessary, as I ended up pulling full days most of the week. I learned a great deal about how to use WinNonLin on Monday, and Tuesday and Wednesday were kidney clinic days at the SOTC, so I was actually able to screen the patients coming in and recruit them myself. I got 4 more patients recruited, which brings my number up to 16 now. It felt great to pass the halfway mark, but I know I need to keep on truckin’ to get all 30.  I also worked a lot on my organizational structure and found that I could assemble a lot more of the paperwork for each patient beforehand, so as to lessen the workload on the days that the patients actually come in. It was an amazingly productive week, and I am hoping that by my next full project weeks in February (aside from Christmas time) I will have all 30 patients recruited and hopefully completed as well.

3) Now I am preparing for Monday, when I start in the ICU at VGH with Gabriel Loh. I am very excited for this rotation, but also intimidated, since it is an area of high acuity, high consequences, and a lot of drugs I don’ t have much experience with. My hopes are to learn the processes, and be able to keep up with the learning and associated workload, so that when I am done I can feel somewhat comfortable practicing in the ICU.  I have worked with Gabe earlier, when I taught an Academic Halfday on electrolyte disturbances, and I am very excited to work with him again. 

Now, in the meantime, it is dumping up in Whistler, so I am off to see some old friends, and hike up the mountain for some pre-season pow turns.

Done with MUM

Today ends mine and Andrew’s Medication Use Management rotation. This second week we worked on preparing 2 separate SBAR statements about a similar issue. I was writing a statement about the potential inter-brand differences in heparin between PPC and Hepalean brands, specifically with regard to bleeding rates. This stemmed from some controversy out east, where an observational study showed higher bleeding rates with PPC brand versus Hepalean brand heparin (although results were non-significant).  After much legwork, I came to conclude that we don’t really know if there is a difference, but USP standards and Health Canada deem the two products bioequivalent, so there shouldn’t be a difference. To read the full article, click here:

SBAR Heparin Inter-brand Differences

This week I also had the chance to teach part of an academic halfday session.  On Wednesday Sharon Leung and I taught our resident colleagues about electrolyte disturbances with the expert guidance of Gabrial Loh; Sharon talked about potassium and magnesium, and I talked about calcium and phosphate disorders. It was a relaxed discussion and I was happy to see it go smoothly.  I look forward to my next opportunity to teach, which will be an academic halfday about ventricular arrhythmias with Doson Chua in March.

Next week I start my Toxicology rotation at DPIC, which should be an interesting week. I am hoping to learn an effective empiric approach to managing a poisoned patient, as well as pick up some therapeutic strategies for specific substance poisonings, such as benzodiazepines and narcotics.

Also, my first project patient came in this week, so I can now say I have pharmacokinetic data for 1 patient (well, data pending the HPLC and Mass Spec…)! Only 29 more to go.

MUM Update

One week has passed of my Medication Use Management rotation, and we have one project down. Last week Andrew and I worked on updating the formulary review that was trying to decide which echinocandin antifungal to carry on review.  Some people had told me that working in MUM could be pretty dry, but I found I was working with a bunch of fungi’s! Get it?!?!! Ok, I’ve been sitting infront of a computer for too long.

Antifungals aside, MUM has been a good experience so far. It is interesting to see what goes on for an MUM pharmacist, and the work that is involved. Similar to Grant submissions and Ethics submissions in research, formulary reviews can be tedious processes where lots of time (often it can seem too much time) is spent on how to word the conclusions.  It can often be overlooked as a clinical pharmacist just how much work goes into choosing the drugs that we carry in hospital.  I think it would be a great role to take on after having a few years of clinical experience under one’s belt.

Starting up in our second week, we have a new task to work on. There has been a lot of controversy recently about the inter-brand differences in Heparin. This stems from an eastern hospital that switched from Hepalean brand to PPC brand heparin, and observed an absolute bleeding rick increase from ~1.6%-4.8%, and then back down to 1.6% when they switched back to Hepalean.  Furthermore, the FDA is now in the process fo changing their Heparin formulation, which is supposedly going to lower the heparin potency by 10%, with Canada scheduled son to follow. Andrew and I are currently searching for the evidence and reasons behind these rumors, and will hopefully find enough to come up with an SBAR statement on the topic. Stay tuned.

Also, I am presenting this week’s Academic Halfday with Sharon on Wednesday, where we will be talking about Electrolytes, specifically potassium, magnesium, calcium, and phosphate.