Sunday, June 21, 2015

Rotation 1: Medical Code, ETA: 5 Minutes

Posted by Rachel Wein at Sunday, June 21, 2015

I cannot believe how fast the last 5 weeks have flown by! If you had told me at the beginning of my first rotation that I would feel comfortable treating patients in the emergency room, I would have laughed. The emergency room is a unique experience, whether you're a pharmacist or a physician as you never know what could walk through the door. In fact, at the large hospital I'm doing my rotation at, I was exposed to just about everything you could imagine; whether it was an eye out of its socket (good thing I'm not squeamish!), lithium toxicity, or heart attacks. As I'm sure you're guessing, I was beyond nervous my first day, more so due to the fact that a medical code came into the resuscitation bay just as I walked in the ED satellite pharmacy. Without any hestitation, Dr. Suprat Wilson (my preceptor and leader in emergency pharmacy) and I jumped right in to help a severely hypoglycemic man with a blood glucose of 23, providing the physician with both oral glucose and an amp of dextrose.

Here's a brief run-down of how the ED operates. When patients come through triage, their vitals are taken by a triage nurse. There are a total of 6 modules a patient could be placed into with a transition of care unit reserved for those being admitted. If certain baselines are not met during the triage interview, for example; if the blood pressure is too low, heart rate is too fast, or oxygen saturation is too low, a patient becomes a "medical code," meaning they need attention ASAP. Additionally, if a trauma code comes in via EMS, it will be designated as either TC1 or TC2 based on a patient's mental status. For a trauma code, the surgical team also attends. The ED pharmacist is both integral and essential in providing assistance to the emergency team.


Over the past 5 weeks, I have seen a wide array of medical emergencies. It's amazing to learn about something in the classroom and then see it happen right in front of you. The biggest eye-opener was how fast Narcan works. The patient comes around very quickly. They are often combative due to their "high" being taken away, but that drug can seriously reverse any opiod. I saw gangrene on the foot of an older gentlemen, causing sepsis and beyond vasopressors, fluids, and antibiotics, the only thing we could provide was amputation. Another bubble that burst was the size of gun-shot-wounds. They are not as big or as bloody as you would expect. During any medical code, Dr. Wilson was amazing at asking me to assess the patient and think about why they might be in the ED and what our course of action might be. This skill will undoubtedly help me in my future rotations and career.


One of the biggest aspects of emergency pharmacy is ACLS and Rapid Sequence Intubation. These were two core topic discussions Dr. Wilson and I talked about. In an ACLS code, the pharmacist is responsible for getting together the epinephrine, reminding the physician when another epi is due (1 mg every 3 min!) and is consulted for what life-saving drug to try next. By the end of the rotation, I was running the pharmacy side of ACLS (with supervision of course). I also got to do CPR for the first time - very hard and tiring! Additionally, if a patient has head trauma or needs ventilatory support, there are many pros and cons to which sedating agent and NMBA blocker to use. The pharmacist is utilized for this too. I can tell you, seeing an intubation in person is way different than on Grey's Anatomy - it looks painful!


In addition to working closely during medical codes, I got proficient at dosing heparin, vancomycin, and TPA. I was able to attend "Wildnerness Emergency Medicine Grand Rounds," where rabies, heat stroke, and seafood toxins were described in detail. Did you know that rabies is actually more common in cats, not dogs? I volunteered myself for two midnight shifts as well as my normal day hours and it was interesting to see how a quiet night can turn into the busiest six hours you've ever experienced. Dr. Wilson was very gracious in letting me see any procedure that happened within in the ED. I accompanied patients to CT, saw the effects of procedural sedation (propofol and ketamine), watched a shoulder be popped back into place and even saw a neurosurgeon drill a hole into a car accident's victim head to reduce the intra-cranial pressure.


Overall, this rotation was incredible. Not only was it highly informative, but I truly enjoyed the entire pharmacy and ED staff. I came into the rotation thinking about ED pharmacy as a possible career, but now I am highly considering it.


Stay tuned - next rotation I will be in Washington DC with the Food and Drug Administration!


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