Monday, October 8, 2012

The Keystones Project: UM Surgical/Critical Care

Posted by Bex Kurian at Monday, October 08, 2012

First and foremost, I’d like to shout out to the Breakfast Club: Victor “A little higher on the skinny tie clip” Truong, and J “Customize that sushi roll please” Fong. Without these compadres gracing me with their presence each morning at the crack of dawn, I attest that I would not have made it through this rotation (we all know how I feel about sleep). I would also know less about the finer intricacies of breakfast. 
Additional shout outs to Mary and Neil (the critical care cohort!), Courtney, Dave, Corinne, Edwin (lunch club), all other pharm students I saw around, and TrisAnn, our angel of knowledge and classy outfits. You guys really took it to the next level.
Oh yes, and I’d like to throw out there: Keystones, wherever you are—do you have a blow-dryer?

Rotation at the UM Surgical Intensive Care Unit was an incredible experience! I have never worked harder in my life. This is the kind of place that makes you realize what the Michigan Difference truly is. I was beyond impressed by the thoroughness and dedication shown by our team each day, for each patient. The whole rotation just blew my mind. Sometime you should just sit me down, or catch me in the hallway, and ask me to tell you about it. Really, I won’t think it’s weird. I want to share so much more than this little blog!

There is a crucial role for the pharmacist in the SICU; our preceptor was trusted and relied on for information every day on rounds.  Every day, I wondered: how does he just know? How does he remember that? How does he not get all the patients mixed up?!
Yeah. Still don’t get it. I can only hope to attain that level of ballitude in the future.

The most common intervention involved antibiotics, as the med student or resident did not always have access to the most up-to-date culture & sensitivity results. Other opportunities for recommendations involved home meds, keeping track of “day-of-therapy” for antibiotics, and dose adjusting for renal function/CRRT/IHD. As the pharmacist, you are also the go-to for basically any drug info question. What’s the max dose? How is it eliminated? What are the big adverse effects?

As students, we each followed patients (evaluated drug therapy, made sure each medication had an indication, kept track of PRN med use, followed up with cultures, etc) and reported to our preceptor after rounds. By the end of the rotation, we were throwing out recommendations to the team! 

Throughout the 5 weeks, almost every area of pharmacology/therapeutics that makes me sad, uncomfortable, and slightly nauseous was addressed. Receptors of all kinds. Words like cholinergic and antimuscarinic were being thrown around. Ionotropes (shudder). Antibiotics covering a bug, but only covering it about 60%-- making a different agent a better choice. That crazy chart from renal with the Ca++ and phos.  
I began to realize that I don’t know things I thought I knew. My preceptor would ask me what a medication was, and I’d be all excited like stool softener! K+ sparing diuretic! Pressor! But then he would say Okay, so how does it work?
…….. Um.
Well you see, it has to do with… the Na/K pump.
Beta receptors.
Resistance?
Okay, I’ll get back to you.

As usual, I will grace you with some of my observations from spending a month in the SICU:
  • Attendings have different styles. 
  • There should really be more evidence. Just, you know… like. More of it. All.  
  • Patients are real people. They are moms, dads, brothers, sisters, sons, daughters.
  • Sometimes, people’s vanco levels don’t make sense. They just don’t. And no one knows why. A real challenge when you think you’re the problem. Don’t forget, though, that generally you are the problem. Okay, maybe just me.
  • It was immensely gratifying to see results right away. Some of these drugs work FAST, and they DO their job. Like it’s their JOB.
  • Medicine is amazing. The things made possible by technology are absolutely beyond my level of comprehension. The longer I think about them, the less and less they make sense. ECMO, mechanical ventilation, CRRT…. Foreal. SO out of my league of thought. Like, not even playing the same SPORT as my league of thought.

To my esteemed colleagues and friends: Halfway done?! It’s all downhill from here!
Wait, no. That came out wrong. You know what I mean.

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