Sunday, March 2, 2014

The Pediatric Intensive Care Unit (PICU)

Posted by Unknown at Sunday, March 02, 2014

Since day 1 of pharmacy school, I had maintained that working with sick children is something I would never do. I've always preferred geriatric (people over 65 years old) populations. Children were out of the question; too difficult to manage their drugs and too upsetting to see sick kids - just not the environment I wanted to be in. But then I had a couple great professors in therapeutics courses who specialize in peds (pediatrics aka children); and then I took the peds pharmacotherapy elective course in P3 year and my opinion gradually shifted – well I at least became open to the idea. One thing I have come to realize as my pharmacy education at the University of Michigan has progressed, is how fortunate we are for the truly high-quality educators we have; and how some faculty will really go out of their way to listen to students’ concerns and offer advice when they are feeling conflicted. But I am starting to ramble, so…

Rotation 5 was in the pediatric intensive care unit (PICU) at Mott Hospital here in Ann Arbor. Dr. Elizabeth Beckman was my preceptor. The PICU had two teams each with attending physicians, fellows, resident physicians, nurse practitioners (NP), and Elizabeth to cover both teams, plus the two of us pharmacy students.  I was lucky to have my classmate and friend, Lydia, on rotation with me. (Challenging rotations are so much better when you are working with a friend and sharing the struggles and the triumphs.) Lydia and I each had our own team and we were responsible for the patients on our teams and attended rounds every morning. On most days we would arrive between 6 and 6:30am to work up our patients and talk to the nurses who were taking care of the patients overnight. Typically there were 8-11 patients on each of our teams, but that number could really vary day-to-day. Rounds would last anywhere from 2 hours to 4 hours depending on the acuity of the patients and the attending’s tendency to teach during rounds. When working up our patients, if we noted medication issues we would share our recommendations with Elizabeth first and then talk with the resident or nurse practitioner for that patient. There was already a very good working relationship established between the physician/NP team and pharmacy so recommendations were generally received well and often accepted without issue. After rounds we would again look over our patients’ profiles and note any changes. Then we would present our patients and have a pediatric-focused topic discussion with Elizabeth. There were also journal club presentations and pharmacy resident or medical resident presentations to attend.

This rotation was a challenge because of the steep learning curve and the patient population involved.  I was as prepared as possible for this rotation as far as coursework was concerned. I had taken both the peds elective and the critical care elective. What I wasn't prepared for, that no coursework could have prepared me for, was the emotional aspect involved in caring for children (and the family) who are in critical condition. For example…..getting to soothe the cries of a toddler by playing with them while the nurse is busy and the parents have taken a much needed rest, is a fun perk to the rotation. However, watching that same child crash onto ECMO (Extra Corporeal Membrane Oxygenation aka lung-bypass-machine) because the child is not effectively breathing on the very next day, is heart breaking. But then, when that same child is well enough to be weaned off ECMO and breathing on their own, and recovering such that the child goes home healthy and happy, well, that’s more rewarding than can be described. There was also a nearly indescribable moment when a different child who had been fighting for their life from an infection for 4 weeks of my rotation, finally had the ventilator tube removed from their throat and woke up enough to ask for pizza….it was amazing.

I left this rotation with a lot more knowledge and an even greater amount of respect for the professionals that treat sick children on a daily basis. Of course the medication dosing is extra complicated with no set doses and there is zero margin for error (children receive weight-based dosing for almost all medications), but also because a PICU in particular is an emotional roller-coaster. It takes a very special person to be a pediatric pharmacist. I had a great experience on this rotation and I really loved being around children, but I realized that I would probably be burned-out quickly from a career in this setting. Maybe my initial thoughts about pediatric pharmacy career options were a little too absolute, but I think I do still prefer the geriatric population if I had to choose a clinical pharmacy career path. 

Here is a special contribution to the blog (and special thanks to Lydia Benitez) to provide a different perspective of this rotation based on Lydia’s experience:

Status asthmaticus is a serious disease event that is frequently seen in the pediatric intensive care unit (PICU). There is a fairly standard treatment algorithm to guide the treatment of a child with status asthmaticus that is tailored to the patient depending on their needs. My experience in the PICU provided me the opportunity to care for multiple patients with status asthmaticus. One particular child’s case really hammered in the importance of intraprofessional communication. While gathering the medication history for a young boy, his mother told me that he was only on a rescue inhaler (albuterol) and had never been prescribed controller medications (inhaled corticosteroids). After contacting the patient’s home pharmacy to gather more information, and I found that he had received multiple courses of antibiotics and steroids from different urgent care facilities in the last year. I also discovered that he had been prescribed a controller inhaler once, but it had never been refilled. With this information, I went back to the medical team and we changed our approach to the situation. Instead of providing the standard training on new inhalers which would be prescribed, we could now focus on addressing specific factors pertinent to this particular child. We discussed the barriers to adherence with the controller medication that had been prescribed in the past, educated the patient and his family about the importance of using controller medications, and worked to ensure the patient had more cohesive care. The medical team contacted the patient’s primary care physician and shared information about the multiple exacerbations and our treatment plan for discharge. We were able to really help this patient by overcoming the immediate crisis and maybe more importantly, reduce the risk of future exacerbations and hospitalizations. By collaborating with the outpatient pharmacy team I was able to acquire information that would otherwise be unknown to our team. In a case where previous medical care was very fragmented, the patient’s community pharmacy of choice was constant, and by collaborating with them we were able to provide personalized care.    

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