Corticosteroids, Contagions, and Creatinine Clearance

Posted by Salem at Saturday, August 28, 2010

I spent the first month of my P4 year with Dr. Cesar Alaniz. He is the clinical pharmacist in University Hospital’s critical care medicine unit (CCMU). The CCMU is an intensive care unit that takes care of U of M’s most critically ill patients. Unfortunately, most of the patients were so sick, that we couldn’t speak to them. Sepsis, hospital-acquired pneumonia, and GI bleeds were some of the common chief complaints of the patients we cared for. This made for an intense (no pun intended), but excellent 4 weeks.

Week 1

I remember being very nervous on the first day. Practically sweating through my freshly ironed white coat, I wondered if I had reviewed my list of antibiotics thoroughly enough. Dr. Alaniz told us to look at the charts of a few patients, and then join him on patient care rounds the next day. I did this, and by the time we finished rounding on Tuesday, I was totally bewildered…

Why are these physicians spending so much time discussing ventilator settings?

What on earth is a galactomannan assay?

Why are so many of these patients on hydrocortisone?

What is the pharmacist’s role in all of this?

How do I use all these computer programs?

Whenever the attending physician, or any of the other members of the medical staff had a drug question, they would turn to Dr. Alaniz. He was able to quickly and confidently answer their esoteric questions like...

“How much Precedex is lost during hemodialysis?”

“What’s the dose of an ampho B bladder wash?”

“How should we redose tobramycin after a one-time of 340mg with a 4 hour random level of 6.8?”

Would I ever be prepared for these types of questions? For the rest of the first week I found myself waking up at 4 AM just to keep up with everything that was happening with our patients. Early!

Week 2

By week 2, Dr. Alaniz had us analyzing the aminoglycoside and vancomycin blood levels of the patients on our service. He wanted us to evaluate the levels and see if the dose of drug the patients were receiving was appropriate. This was not nearly as straightforward as it had been in class. All of the patients were in some stage of renal failure. So the numbers we would use for our calculations would fluctuate up and down, up and down. Curveball!

Week 3

During week 3, we only had a few patients on our service. Dr Alaniz decided that due to the “paucity of patients” he would let me start rounding without him. This totally changed my experience. Any drug-related questions now came to me - and there were some hard ones...

“Do we need to continue vancomycin in this patient?”

“How do we taper methylpred after anaphylaxis?”

It was great when I was able to provide an answer, but it was a little embarrassing when I couldn’t. Pretty thrilling!

Week 4

By week 4, I was a part of the team. I could make recommendations, and answer questions much more comfortably. I could definitely have learned much more from a few more weeks at the CCMU.