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Emergency

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What this rotation helped me achieve?

I have become more familiar with medications used in the emergency setting, become better at writing more succinct notes, analyzing pharmacokinetics of medications (digoxin, phenytoin, vancomycin etc.)
I have developed more faith in the contributions made by pharmacists. I have come to realize that pharmacists have the ability to prevent a lot of medication errors be it by medication reconciliation, finding drug related problems, educating a doctor or nurse about a new medication and it’s adverse effects or finding the drug cause of a medical problem.

Some other new concepts I learnt:
Subdural hematoma: collection of blood on the surface of the brain. This is a serious condition since the increase in intracranial pressure can cause damage to brain tissue and loss of brain function.

Bethanechol: Treatment of acute postoperative and postpartum nonobstructive (functional) urinary retention; treatment of neurogenic atony of the urinary bladder with retention

Emergency

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Presentation on CIWA Protocol:
CIWA

Diagnostic Tests Used:
CT Scan
MRI: A noninvasive technique for visualizing many different body tissues. Unlike x-rays, MRI does not use any radiation. Instead, it uses radio waves, a large magnet, and a computer to create images.As with a CT scan, which does use x-rays, each MRI picture shows a different “slice,” or cross-section, of the area being viewed. An MRI of the brain can identify tumors and areas of brain damage caused by a stroke or another neurological condition.

Echocardiogram: Ultrasound of the heart to examine heart valves, how forcefully heart pumps blood, determine the size of heart, and assess how well it is functioning. It can spot areas of the heart wall that have been injured by a previous heart attack or some other cause.
TTE: Transthoracic echocardiography is the primary noninvasive imaging modality for quantitative and qualitative evaluation of cardiac anatomy and function. The test is useful for assessing the size of the heart chambers and walls, heart muscle function, heart valve function, blood clots or masses in the heart, fluid around the heart, presence of holes or defects between the heart chambers, and abnormalities of blood flow within the heart.

TEE: A type of echo test in which the ultrasound transducer, positioned on an endoscope, is guided down the patient’s throat into the esophagus. The TEE test provides a close look at the heart’s valves and chambers, without interference from the ribs or lungs. TEE is often used when the results from standard echo tests are not sufficient, or when doctor wants a closer look at the heart. TEE may be combined with Doppler ultrasound and color Doppler to evaluate blood flow across the heart’s valves.

Doppler ultra-sound: A noninvasive test that can be used to measure your blood flow and blood pressure by bouncing high-frequency sound waves (ultrasound) off circulating red blood cells.
ECG
Chest X-Ray

Topics discussed:

Clindamycin use in cellulitis, necrotizing fascitis: appears to have an anti-toxin effect against toxin elaborating strains of streptococci and staphylococci.
Clinicians should consider the possibility of laboratory error, sampling error or blood-sample hemolysis before initiating therapy, especially when patient is asymptomatic and electrolytes were previously normal with little or no change in therapies or clinical condition.
Major organ involved in electrolyte and fluid hemostasis: kidney
Recommended to use adjusted body weight in obese adult patients
AdjBW(men) = ([wt in kg – IBW in kg] x 0.3) + IBW)
AdjBW(women) = ([wt in kg – IBW in kg] x 0.25) + IBW)

Serum osmolality: (2 x serum sodium conc. in meq/L) + (serum urea conc. in mg/dL/2.8) + (serum glucose conc. in mg/dL/18)

Hyponatremia: Symptoms: headache, lethargy, disorientation, restlessness, nausea, vomiting, muscle cramps or weakness, depressed reflexes, seizures, coma, death, altered mental status, seizures. Identify and correct reversible cause of hyponatremia e.g. excessive i.v. administration of hypotonic fluids, such as 5% dextrose injection.

Hypertonic normal saline is a dangerous medication as incorrect rate and volume can lead to permanent neurologic complications, including central pontine myelinolysis which manifests as a gradual onset of neurologic alterations occurring within 1-6 days of rapid correction. Findings may include pseudobulbar palsy, quadriparesis, seizures, and movement disorders. [Source: Treatment of electrolyte disorders in adult patients in the intensive care unit Am J Health-Syst Pharm Vol 62, 2005]. My preceptor shared some real stories and went over the calculations with me on how to find out if the order is safe or not. The maximum recommended increase in serum sodium concentration is 8-12 meq/L per 24 hours with complete correction over 48-96 hours. Serum sodium levels should be monitored frequently (e.g. q 2-4 hrs) until the patient is asymptomatic, then q 4-8 hrs until the serum sodium is WNL.

Amount of Na in 1 L of 3% NaCl = 512 meq, 1 L of 0.9% NaCl = 154 meq/L

Hypokalemia
Types of potassium salts used in hypokalemia

Hyperkalemia

Signs/Symptoms/Questions I would ask/laboratory investigations/treatment procedure
Acetaminophen Toxicity, Salicylate Toxicity, Ethylene glycol Toxicity
Know what dose is lethal, how would you treat it, timeline (e.g. when was the drug ingested) is very important in determining how to treat

Indications for use of IVC filter: http://emedicine.medscape.com/article/419796-overview#showall

ACLS
Treatable causes
5Hs: Hypothermia, hypoglycemia, acidosis, hypo or hyperkalemia, hypovolemia
5Ts: Cardiac tamponade, toxins, tension pneumothorax, thrombosis coronary, thrombosis pulmonary
Algorithms

Clinical Interventions:
Dose adjustment according to renal function of piperacillin/tazobactam
Vancomycin/Phenytoin/Digoxin pharmacokinetics
Angioedema
CIWA Protocol: suggested to discontinue
Warfarin dosing
Discontinuation of linezolid (not required as no evidence of endocarditis)
Streamlining of antibiotics
Assistance with adherence (called patient’s pharmacy to inform about patient’s decision to get her medications blister-packed)
Called Pharmanet to request special authority
Educated patient on how to use MDIs
Medication Reconciliation
Improvement in Triaging: More efficient with time
DRPs

Emergency so far…

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Gradually, I am learning to be skeptical about everything as the key is to question everything unless you are convinced why something is being done. Physicians are great at diagnosis but it is my role as a pharmacist to make sure everything pertaining to medications is being taken care of. My preceptor has shared many real examples from her practice which have made me realize how important it is to convince myself. For example, if someone has recently been diagnosed with atrial fibrillation and I have been asked to anticoagulate the person, I am not just going to blindly follow that. It is my responsibility to ask is this drug even indicated, is the dose effective and safe. May be the patient has hypethyroidism which can be treated before I think of starting an anti-coagulant.
As a licensed practitioner, I have the right to say no when something doesn’t make sense to me and I feel it is unsafe for the patient. For example, my preceptor shared a case where a patient was put on ASA, plavix, warfarin and heparin all simultaneously in an acute stroke. Even if the physician disagrees with me, I need to voice my opinion and chart my role in the process.

Topics discussed:
Advanced Cardiac Life Support
Phenytoin dosing

Wrote notes in the chart re:
Digoxin, warfarin and phenytoin dosing

Emergency is a busy atmosphere but I find it very rewarding as it provides me to exposure to lots of different disease states. I am being given the opportunity to talk to different physicians and make changes to the orders. This is being very helpful as my communication skills and confidence will only improve with more practice.

Emergency Medicine: Week 1

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Goals:

1. Pharmacokinetic interpretation and documentation of phenytoin levels for at least 1 patient
2. Pharmacokinetic interpretation and documentation of vancomycin and aminoglycosides of at least 2 patients
3. Read and discuss topics with my preceptor on: electrolyte imbalances, seizures, stroke
4. Apply concepts of electrolyte imbalance treatment and work up at least one patient

This week I did not get to spend much time on the ward due to job fair and exam.
Monday: Orientation, Patient Triage introduction, worked up one patient with hypernatremia
Thursday: Worked up one patient, attended a presentation at a local high school by my preceptor exposing high school students to role of a hospital pharmacist as part of the Pharmacist Awareness Week
Topic discussed: Diabetic Ketoacidosis in Adults
Friday: Triage, Followed up one patient from Thursday, worked up a new patient

Concepts/terms I looked up so far:

1. Double disk diffusion test: Performed for the detection of inducible clindamycin resistance. Some isolates of Staphylococcus aureus have in vitro resistance to erythromycin and susceptible to clindamycin.
The disk diffusion (D-test) method can detect S. aureus isolates with inducible macrolide-lincosamide-streptogramin B (iMLSB) resistance.

2. Plt clumps/EDTA:EDTA-induced platelet clumping is possibly the most common cause of pseudothrombocytopenia. EDTA (ethylenediaminetetraacetic acid) is the most commonly used anticoagulant in evacuated tubes. EDTA reduces platelet activation by protecting the platelets during contact with the glass tube that may initiate platelet activation. Activation causes platelets to clump in the presence of calcium and platelets adhere to the glass surface at a rapid rate. Chelation of calcium using EDTA results in decreased platelet adhesion or retention to glass.

3. GJ feeding tube: gastro-jejunal feeding tube.
Medication administration through enteral feeding tubes: http://www.medscape.com/viewarticle/585397

4. IVC filter: http://www.guidelines.gov/content.aspx?id=15730

Cannulation is the process whereby a cannula (a small hollow plastic tube) is inserted into and kept inside the vein for a period of time.

5. Evidence behind use of CCBs in heart failure:

6. Troponin I timeline: http://www.ecmaj.ca/content/173/10/1191.full

7. Uncapping dalteparin: LMWH in Renal impairment and Obesity

8. Prolia (Denosumab): Can cause hypocalcemia (symptoms: Spasms, twitches, or cramps in muscles, numbness or tingling in fingers, toes, or around mouth)

Click to access UCM214385.pdf

9. ESBL treatment: Carbapenems are the most reliable and most effective. Among the available carbepenems, meropenem is the most active against ESBL-producing organisms in vitro, with MICs generally lower than those of imipenem (0.03-0.12 µg/ml vs 0.06-0.5 µg/ml).

10. Aspiration pneumonia antibiotics (Source: Bugs and Drugs)
Community-acquired or nursing home acquired pathogens: S. pneumoniae, H. influenzae, S. aureus, Enterobacteriaceae (Alcoholism and enteral feeding may be risk factors for colonization with these organisms)
Antibiotics recommended: Cefuroxime IV/PO 2. Gatifloxacin or Levofloxacin or Moxifloxacin for 7-10 days

Community-acquired or nursing home acquired with poor oral hygiene, severe periodontal disease, putrid sputum: S pneumoniae, H. influenzae, S. aureus, Enterobacteriaceae, Oral anaerobes, Streptococcus spp, Eikenella corrodens
Amoxicillin-clavulanate or Cefuroxime IV/PO + Metronidazole Iv/PO
Gatifloxacin or levofloxacin or moxifloxacin + metronidazole IV/PO
Treat for 7-14 days

11. BOOP (Bronchiolitis obliterans with organizing pneumonia): A rare lung condition in which bronchioles and alveoli become inflamed and plugged with connective tissue. The disorder is also known as cryptogenic organizing pneumonia (COP). Associated with other health conditions:
Infections. BOOP sometimes occurs after people have had certain infections, including chlamydia, influenza or malaria. (2) Inflammatory disorders: Risk appears to be heightened for people who have disorders such as lupus, rheumatoid arthritis or scleroderma. (3) Chemotherapy or radiation can put you at risk of developing BOOP. (4) Transplanted tissue. Bone marrow, lung, kidney and stem cell transplants sometimes trigger bronchiolitis obliterans with organizing pneumonia. (5)Drug exposure (include cocaine, gold salts and some antibiotics and anti-seizure medications).

Most people recover after weeks or months of treatment prednison but in some it can progress in spite of treatment. Source: MayoClinic

12. Glicliazide and renal insufficiency: Avoid renal function of 10-50 ml/min and <10 ml/min
Source: Dosing guidelines for Adults:
13. Phenytoin:
Dose related side effects: drowsiness, confusion, nystagmus, ataxia, slurred speech, nausea, unusual behavior, mental changes, coma
Non-dose related side effects: hirsutism, acne, gingival hyperplasia, folate deficiency, osteomalacia, hyper-sensitivity reactions, steven-johnson syndrome

Pediatrics Final Week

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Overall, this rotation was a great learning experience. Lots of lessons learned for the future!

Feedback received regarding journal club and case presentation is in the handout. Feedback

Interesting case: Patient on ketogenic diet for seizure prophylaxis. As a pharmacist, my role was to make sure to use medicines that do not add excessive glucose to her total intake.

Other tasks performedEpipen teaching
Making phenobarbital suspension from tablets
Gentamicin levels x 2
Vancomycin levels x 2

Topics discussed
Anaphylaxis
Asthma
UTIs

Things to keep in mind:
Check the date and time of diagnostic tests
Report and write the dose in mg/kg
Be aware of when the last dose of antibiotics is?
You are the drug expert! Prove to yourself why a certain drug is on patient’s profile. If you cannot, question it!
Be convicted in your recommendation
Use primary literature vs. tertiary
Pharmacists are paid to think, you are the problem solver!

Summary of jaundice from a handout:
Not a disease, it is a symptoms. It is common in new-borns and in most cases, is a natural part of the newborn’s adjustment to life after birth. May make a baby sleepy and slow to feed, but it rarely causes any problems.
RBC breakdown–bilirubin–eliminated by liver–immature liver–accumulation of bilirubin
Other causes of jaundice:
Premature baby
Infection: may reduce liver’s efficiency
Bruising: bruising during the birth process can result in a larger than usual amount of bilirubin
Mother and baby-blood incompatability
Phototherapy: light changes bilirubin into a harmless chemical. Baby will require more frequent feedings to replace fluids lost through phototherapy.
Breast milk jaundice, occurs in about 1%, cannot be diagnosed until the 2nd week of life.

Pediatrics Week 1

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Goals:

1. Perform and document a pharmacokinetic interpretation of at least one drug besides vancomycin, aminoglycosides
2. Perform and document a vancomycin pharmacokinetic interpretation
3. Provide continuity of care from in-hospital to outpatient setting to at least 1 patient
4. Clarify at least 2 medication orders with the prescriber
5. Counsel caregivers on at least two medications
6. Perform at least one nursing in service
7. Gain understanding of immunizations in pediatrics

Disease conditions worked up so far:
Neonatal lupus
Diabetic Ketoacidosis
Primary ciliary dyskinesia, Bronchiectasis

Presentations attended:
Antibiotic teaching to nursing students by my preceptor
Journal Club by Herb Wong: Intraosseous versus intravenous vascular access during out-of-hospital cardiac arrest: a randomized controlled trial

Topics discussed with my preceptor so far:
Developmental Pharmacology: Drug disposition, action, and therapy in infants and children
Immunizations to be administered in grade 9: Tetanus, Diphtheria, Pertussis Vaccine

Ketoacidosis: high anion-gap metabolic acidosis due to excessive blood conc. of ketone bodies
Ketoacidosis can be seen in following conditions:
starvation ketosis (In adults it can take 3-14 days of starvation to reach maximal velocity, could be 4 hrs in kids, even if they miss 2 feeds)
Alcoholic ketoacidosis
Diabetic ketoacidosis

Psychiatry Final Week

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Tasks performed:
In-service to Psychiatrists, nurses and pharmacists on Memantine + antipsychotics

Memantine Presentation Final

Case presentation: Pisa syndrome

Psych case presentation Final

Counselled two patients on their medications

Clinical Pearls:
Take a lithium level on any patient on Li on admission (2) aim for lower levels in elderly population
Terms I get confused about:
Dystonia: neurological movement disorder in which sustained muscle contractions cause twitching and repetitive movements or abnormal postures. Two forms: acute and delayed

Patient is defined as having metabolic syndrome if the patient has central obesity plus 2 of the following 4 risk factors; elevated triglycerides, reduced HDL, elevated BP, elevated blood glucose

Cardiometabolic monitoring form used by BC Mental Health and Addiction Services monitors for following:
Waist circumference, weight, BMI, blood pressure, fasting blood glucose, Hgb A1c, LDL cholesterol, Total cholesterol, HDL cholesterol, triglycerides, Cholesterol/HDL ratio, ECG abnormalities, QTc

Goals for next rotation:

See more patients: Aim for 1 new patient every day
Follow-up with patients everyday

My goals for psychiatry rotation

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Psychiatry is one of my elective rotations. I have always been interested in this area and I am glad I got an opportunity to learn about it for four weeks and see real patients vs. just learning about it in class. Below are my objectives for the rotation:

1. Interpret and document clozapine level for at least 1 patient

2. Understand the pharmacokinetics and dosing of Valproic acid and lithium

3. Conduct UKU Side effect rating scale, DAI (Drug Attitude Inventory) and AIMS (Abnormal Involuntary Movement Scale) assessment for at least 3 patients

4. Educate at least two patients about their medications

 

 

 

General Surgery: Last week

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Worked up patients on:
Pancreatitis x 2
Cholecystitis
Small bowel obstruction

Topics discusses:
Pancreatitis
Vaccines post spleenectomy
PCA/Epidurals
Electrolyte replacement

Tuesday: shadowed a wound care nurse and observed colostomy change

Thursday: Case presentation
VANCOMYCIN FAILED MY KIDNEYS: NOW WHAT?
Case presentation General Surgery

Feedback:
Much improvement from last presentation: better pace, easy to understand, good pauses
Answered questions well
Good format and layout

What does “Commitment to the profession” mean personally to me?

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Before starting to answer this question, I gave it a lot of thought. It reminded me of the ‘White Coat Ceremony’ back in the first year of pharmacy. The ceremony marks our entrance into faculty and confirms our commitment to the profession of pharmacy. However, back then I did not really take it seriously perhaps because I didn’t really understand the deep meaning. I still had 4 years ahead of me and did not what the journey was going to be like. Conversely, today I believe in the pledge. Here is how and why:

After attending the Networking Night organized by the Canadian Society of Hospital Pharmacists, the amount of knowledge I had about hospital pharmacy and the practitioners working in this setting has expanded. Everyone is so different and has so much to contribute. The stories describing their journey to the world of pharmacy are different; some are here by chance, some wanted to pursue hospital pharmacy since the early days of their high school or post-secondary education but one thing that binds them together is their passion for patient care. They love what they are doing! And that is why they were at the educational sessions, travelled miles to listen to their colleagues, asked questions and engaged in discussions.

Patients come first. When I decided to pursue a career in pharmacy, I knew that there is no room for “9-5” attitude in this profession; I should be available for my patients whenever required. And yes, when I spoke to the practitioners present at the residency networking night, I felt like I didn’t know anything and wondered how I would ever get to that stage and what if I make a mistake. However, at the same time I have to remember that practice makes one perfect and these feelings are normal at the beginning. The more I ask questions to my preceptors, complete the assigned tasks and make the best of the opportunities provided to me, the easier it would be for me on the day when there is no one to watch me and when I will be fully responsible for taking care of my patients myself. In order to become a competent health professional and provide the best care to my patients, I will work hard.

There is no way I will retain everything or know everything about pharmacy but my focus is to make my best efforts to keep myself up to date with current and new knowledge. One of the reasons I decided to pursue pharmacy and then hospital pharmacy is because I enjoy challenges. Change excites me! Browsing through books or internet to find out an answer is what keeps me going! I remember when I was doing my 4th year rotation at Nanaimo Regional General Hospital, I was always looking up information; be it an abbreviation used by the doctor, a drug I had no clue about or any procedure mentioned in the discharge report or a patient’s chart. There were times when I got to the hospital at 7 am in the morning and left at 7 pm at my own will. Not because I was told to be there for so long, but because I enjoyed what I was doing! I have heard numerous stories about residency being intense and then you hit a point where your brain is full and you cannot take it any more. It might be the case with me at the end, however I am going to keep an open mind and try my best to learn as much as I can. I won’t know everything but my focus is to FOCUS ON THE CONTROLLABLES!

As I mentioned in my residency application, after residency I have future plans which will keep me in the student mode. Not sure when yet, but I am interested in doing a PharmD and in the future I would like to be a preceptor for undergraduate students and future Pharmacy Residents. This way I will get an opportunity to give back to the profession and make a difference.
After typing my response to this question, I decided to google what other people have to say about commitment to profession. I stumbled upon this book, Professional nursing: concepts & challenges by Kay Kittrell Chitty. Comparing profession with occupation, she states that professions consider their profession as an integral part of their life. They gain satisfaction from their work which surpasses their desire for money or other materialistic rewards. I remember back in first year when I shadowed a pharmacist at Surrey Memorial Hospital, he told me a similar story. He mentioned that even though his earnings would be higher as a community pharmacy, it is the job satisfaction that encouraged and inspired him to work in the hospital setting.
Therefore, I am looking forward to another year of being a student as a resident and hopefully more to come….