Friday, January 10, 2014

Critical Care Catch-up

Posted by Ashley Wester at Friday, January 10, 2014

Whew! P4 year has really been a whirlwind thus far! I wanted to take the time to catch up on some of my blog posts from the last several rotations, so these next couple posts will hopefully bring everyone up to speed on how things have been going so far this year! This post will discuss my 10 solid weeks of critical care rotations, and how things went along the way. Enjoy!

Medical Intensive Care Unit at Sinai-Grace Hospital in Detroit, MI
I was extremely excited to begin my inpatient critical care rotation at Sinai-Grace. As my first inpatient rotation, it was a little intimidating to step onto the unit at first. These adult patients were very different from the pediatric patients I was used to caring for at my job at C.S. Mott Children’s Hospital; many of them had multiple comorbidities and complex diagnoses, and at first I really doubted my ability to care for this type of patient population. My preceptor, Dr. Mark Pangrazzi, had been working on this unit for the past year, directly from his residency training, and had already developed a solid relationship with the physicians and nurses on his team. Though I was a little nervous at first, Dr. Pangrazzi was excellent at easing me into the rotation and ensuring my understanding of the disease states and drugs we use to treat them.

Each day, I would make the 40-minute drive from Ann Arbor to Detroit for rotation, generally arriving by 7am. Dr. Pangrazzi and I were responsible for the two teams that operated in the MICU, which meant that each day we would have to alternate which team we were rounding with. I would spend a little over an hour working up my patients each day, being sure to address any medication-related issues and anticipate any changes that may need to be made during rounds. As time went on, I developed my own relationship with each of the teams and was able to make my own recommendations and round by myself.

I quickly learned that things can change in an instant in the MICU. There were multiple occasions where patients would decompensate; they would be stable one minute and in full-blown cardiac arrest seconds later. During each of these circumstances, quickly and calmly, my preceptor began preparing emergency medications for administration during each code blue. Though I had some experience with emergency drug preparation through my experience as a pharmacy technician, the adrenaline was always pumping just as high as ever. I learned a lot about life-saving measures pharmacists can take to be prepared for these types of situations, and I definitely feel more confident in my ability to be a vital member of a code team after these experiences.

Besides gaining an abundance of clinical knowledge, I also really enjoyed our weekly topic discussions. Some of the things I explored during my rotation included stress ulcer prophylaxis, intensive insulin therapy, COPD exacerbations, and aneurysmal subarachnoid hemorrhage. Additionally, I prepared a journal club presentation for the pharmacists on rapid blood pressure lowering in patients with intracranial hemorrhage. Overall, I really enjoyed this critical care experience and would recommend it to anyone looking for an interesting and challenging rotation!

Pediatric Cardiology at the University of Michigan C.S. Mott Children’s Hospital

While this rotation was probably the most intimidating title on my list of rotations, I was ecstatic to get back to C.S. Mott Children’s Hospital! Coming off of an adult critical care rotation, I was feeling prepared for another challenging critical care experience, this time involving the most delicate of babies. I was familiar with the Pediatric Cardiothoracic Intensive Care Unit, as it was one of the units I worked in during my time as a pharmacy technician. However, over the course of the 5-week rotation, I learned more than I could have imagined about a unit I had worked in for 4 years. I also wasn’t so sure how I felt about cardiology, as it was a pretty difficult subject to comprehend during therapeutics. However, the patients on our service suffered from congenital heart defects, which encompassed a totally different aspect of cardiology that had not been taught in pharmacy school.

Each day started really early, as I usually arrived between 5:15 and 5:30 am to work up my patients for the day. Before rounds each day, not only would I look up the patient’s most recent labs, but I would also talk to each patient’s nurse about overnight events, along with checking each drip pump to see what dose and rate were running for every medication. I would then meet with the team for morning sign off, and check in with my preceptor, Dr. Regine Caruthers, to run any interventions by her before rounds. One of the things I really liked about this rotation was the independence I was given. The very first day of rotation, I was rounding on my own with my team and fielding any questions to Dr. Caruthers. By the middle and end of rotation, I felt comfortable answering a lot of the team’s questions, and Dr. Caruthers would always support and encourage me whenever I lacked confidence.

I was given the time to learn new things at my own pace, and the bi-weekly topic discussions were extremely helpful. Some of the things I researched throughout rotation included Patent Ductus Arteriosus, Tetralogy of Fallot, Transposition of the Great Arteries, infectious endocarditis, and Coarctation of the Aorta. I also looked into Hypoplastic Left Heart Syndrome and the palliative surgeries performed to correct it, as we had several patients who suffered from this on our service. Additionally, there were several heart transplant patients on our service, so it was a great review of transplant drugs in addition to cardiology considerations. I even had the opportunity to help with discharge counseling for one of our transplant patients! Other patient interactions included performing medication reconciliations for new patients that joined our service. I had the opportunity to explore drug dosing in ECMO, monitoring and pharmacokinetics of antibiotics, and (more) participation in code blue emergencies. Though the hours were long, sometimes up to 12-hours each day, they always flew by and I enjoyed every second of it!
I hope you have enjoyed this post, which includes my experiences on some of my most rigorous, but favorite rotations thus far! I just want to remind underclassmen who may be reading this that though some rotations may seem intimidating at first, they may be extremely rewarding in the end. While I had 10 straight weeks of intense critical care rotations, it really helped me to determine where I may want to focus during a potential residency and has helped me to seek out residency programs that are strong in this area. This whole process is about developing you as a clinician, and discovering where your interests may lie and how you can impact patient care. My best advice is to make the most of your P4 year by challenging yourself through interesting rotations. That’s all for now. Look out for another catch-up blog post soon to recount some of my other experiences! 

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