Adam Loyson
at
Sunday, October 20, 2013
Since writing about my nephrology rotation in the
outpatient/inpatient dialysis unit setting, I am now concluding a rotation in
critical care at a small private hospital. This new chapter of my APPE
experience has been truly amazing, calling upon every bit of my pharmaceutical
knowledge to save patient lives.
Detective work
With my new-found confidence growing from just one rotation
under my belt, I was up for a new challenge. Enter the critical care arena.
Becoming oriented to the intensive care unit (ICU) brought many new
opportunities. Starting from day one, I found myself judiciously evaluating the
complex clinical status and pharmacotherapy of the patients I was following. I also
began participating in multidisciplinary patient rounds for the first
time. Intimidated, yes; but I was
determined to make a difference.
Patients arriving to the ICU from the emergency department were
often diagnosed with numerous disease states, frequently more than I could count
with two hands. These patients required intricate care, with physicians often
asking the pharmacist and me for our advice on the direction, agent selection,
dosing, and duration of pharmaceutical care. With such inquiries, I quickly
found myself becoming a supersluth in researching and recommending solutions
from cardiovascular, respiratory, neural, metabolic, infectious disease, and
gastrointestinal disease state guidelines.
Endless opportunities
An exceptionally neat aspect about rotating in the ICU is the
sheer number of interventions you can make as a student pharmacist. On a daily
basis, I was involved in developing pharmacokinetic and therapeutic plans for
patients receiving antibiotics (e.g., aminoglycosides and vancomycin) and
anticoagulants (e.g., heparins and warfarin). I often encountered patients that
required antibiotics for their recent onset of pneumonia, medications to
convert their heart arrhythmia, or electrolyte supplementation. In these
situations, I was able to educate the new medical residents about the
appropriate agents, medicinal algorithms, and patient monitoring parameters to
use.
In contrast to my last rotation in the dialysis unit, many
patients in the ICU arrived with multi-organ failure. With elevated levels of
acuity, many patients were prescribed complex medication regiments as
inpatients. Thus, I was able to answer
many questions from nurses about drug interactions and intravenous line
compatibility.
Evidence-based
The multidisciplinary team of physicians, dieticians,
respiratory therapists, and nurses often consulted pharmacy services and
inquired about the evidence behind particular therapies or signs of drug
toxicity. My ICU experience served as an
excellent opportunity for gathering drug information, permitting me to evaluate
literature sources for strength and relevance for the individual patients I covered.
For example, a patient was referred to the hospital and
admitted into the ICU after taking four pills of diphenhydramine instead of one
to help her fall asleep. The patient presented to the hospital with abnormal
muscular spasms. After performing a quick search of the literature and
contacting poison control, I recommended that an antimuscarinic agent be given
for treatment.
Another pharmacy service that I participated in was the
monitoring of per-protocol medication administration and assuring that standardized
procedures were being met on a consistent basis based on patient care quality
indicators. Such indicators that pharmacy would oversee include appropriate administration
of a thrombolytic agent during a stroke, a benzodiazepine during alcohol
withdrawal, or venous thromboembolism/gastrointestinal stress ulcer prophylaxis
for patients during their ICU stay. Interventions were made if any practices
were not in agreement with Joint Commission criterion or Medicare reimbursement
models.
Continuous learning
Rounding out my rotation experience, I am happy that I have
been exposed to the continually revolving care of ICU patients and the
treatment of their medical conditions. Whether it is sepsis, hypertensive
crisis, drug overdose, or acute coronary syndrome, I can assure you that I have
learned substantially from the medication management in the critically ill patient
population. I recommend the ICU experience
for any student pharmacists that are interested in challenging themselves and participating
in a coordinated team to treat the extremes of human disease and ensuing
ethical and social dilemmas.
Needless to say, this rotation has been a great opportunity to
help me review for the pharmacy licensing exam!
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