Posted by
Unknown
at
Sunday, October 11, 2015
ORP, OCC, DMEPA, OGD. On my first day, while I was waiting to meet my preceptor, a man struck up a conversation with me (apparently I looked lost). He asked me where I worked, and I spelled it out, Office of Regulatory Policy. He nodded with recognition: "Oh, ORP! I'm from OSE!" I guess I looked confused, because he started explaining some of the abbreviations before he had to run to a meeting. Five weeks later, I still see and hear abbreviations daily that I need to look up.
Working in ORP was completely different from what I expected, but I still absolutely loved it. I was surprised to learn (although it is somewhat implied in the name) that the office is filled with lawyers. Interacting with lawyers in a healthcare setting is very different from working with other healthcare professionals. Some of my office's main responsibilities included participating in the development of rules and regulations and responding to citizen petitions (documents individuals, groups, and companies can write to FDA to try to persuade them to change something, such as remove a drug from the market, issue a guidance or rule, or make labeling changes). In both of these cases, I appreciated having different disciplines working on these projects together. As a healthcare professional, advice and knowledge I felt was obvious was not always clear to others, and vice versa. Having multiple experts from a variety of areas allowed for the clearest documents to be released to the general public.
FDA was not all work and no play, however. I attended nearly daily meetings to learn about all the different departments and met individually with pharmacists from several departments. I also went on several field trips, including the Bureau of Prisons, American Pharmacists Association, United States Pharmacopeia, and the Pentagon. Pharmacists are working all over the world in places you would never expect to find them, and hearing about the variety of opportunities available for those looking for a non-traditional path was informative - many jobs I had never considered, or even heard of before!
Overall, this was a fantastic rotation that went by too fast. I loved the idea that I was affecting pharmacy at a national level by assisting with the creation of various policies. I have always wanted to effect change on a grander scale than one patient, one pharmacy, or one hospital, and at FDA I was able to accomplish that. I look forward to hopefully returning one day, but until then, onwards to pediatrics!
Sunday, October 11, 2015
Friday, October 9, 2015
Rotation 4- Poison Control-
Posted by
E. Caliman
at
Friday, October 09, 2015
My fourth rotation was also at the Poison Control Center, so I had the same experience as Emily in the post below. I was also surprised that knowing the substance the patient took wasn't particularly critical to treating the patient; many times, you just treat the symptoms as they show up. It still made it interesting to guess the substance when we went over cases. I also learned that not every toxin has an antidote, which leads to treating the patient supportively.
Several of the cases involved acetaminophen (Tylenol) in some form, which is to be expected: it's the most common toxin called into poison control centers and the most common cause of liver failure. Alcohol was also very common, as well as a mixture of illicit substances. On the other hand, we got to handle uncommon cases, such as rattlesnake bites (the only rattlesnake in Michigan is the Massasauga), insulin, and fuzzy caterpillars (not poisonous, but the "fuzz" is actually many tiny spines, so it's like a porcupine). It was interesting to see how certain substances were more common to certain age groups. Another interesting point was that the patient may not be telling you the truth when they tell you what they took. Sometimes, what they say they took and what they actually took look completely different.
This rotation highlighted several things we discussed in the American Pharmacist Association's Generation Rx committee about securing your medications. Even though the focus of the committee is young adults getting into their parents or grandparent's medication cabinets, young children also can get access to them if they're not locked, get past child-resistant caps, and consume medications in spite of the taste. One of the cases I consulted for while on call involved a kid about 2 years old who took some of his parent's medications when they were briefly left unattended. Another problem highlighted was that of household products. Detergent pods are very colorful and appealing to children and their contents are under pressure. If a child bites one, some of the liquid detergent can spray to the back of the throat where it can be swallowed, or worse, inhaled. Chemicals found in the garage are also a problem. Products such as antifreeze and brake fluid have a sweet taste, but can cause renal failure, which means the patient may be put on hemodialysis for life.
Overall, this was a great rotation and I'm considering further studies in toxicology. If nothing else, I can expand my knowledge base to better help my patients.
My fourth rotation was also at the Poison Control Center, so I had the same experience as Emily in the post below. I was also surprised that knowing the substance the patient took wasn't particularly critical to treating the patient; many times, you just treat the symptoms as they show up. It still made it interesting to guess the substance when we went over cases. I also learned that not every toxin has an antidote, which leads to treating the patient supportively.
Several of the cases involved acetaminophen (Tylenol) in some form, which is to be expected: it's the most common toxin called into poison control centers and the most common cause of liver failure. Alcohol was also very common, as well as a mixture of illicit substances. On the other hand, we got to handle uncommon cases, such as rattlesnake bites (the only rattlesnake in Michigan is the Massasauga), insulin, and fuzzy caterpillars (not poisonous, but the "fuzz" is actually many tiny spines, so it's like a porcupine). It was interesting to see how certain substances were more common to certain age groups. Another interesting point was that the patient may not be telling you the truth when they tell you what they took. Sometimes, what they say they took and what they actually took look completely different.
This rotation highlighted several things we discussed in the American Pharmacist Association's Generation Rx committee about securing your medications. Even though the focus of the committee is young adults getting into their parents or grandparent's medication cabinets, young children also can get access to them if they're not locked, get past child-resistant caps, and consume medications in spite of the taste. One of the cases I consulted for while on call involved a kid about 2 years old who took some of his parent's medications when they were briefly left unattended. Another problem highlighted was that of household products. Detergent pods are very colorful and appealing to children and their contents are under pressure. If a child bites one, some of the liquid detergent can spray to the back of the throat where it can be swallowed, or worse, inhaled. Chemicals found in the garage are also a problem. Products such as antifreeze and brake fluid have a sweet taste, but can cause renal failure, which means the patient may be put on hemodialysis for life.
Overall, this was a great rotation and I'm considering further studies in toxicology. If nothing else, I can expand my knowledge base to better help my patients.
Friday, October 2, 2015
Rotation 4: The Dose Makes the Poison
Posted by
Emily
at
Friday, October 02, 2015
Despite the clinical nature
of this rotation, my experience at the Michigan Poison Center certainly fit its
“non-traditional” billing. Full
disclosure: I have been very interested in toxicology since shadowing at this
poison center the summer after P1 year (and two more times as a P2), and thus
this was the rotation I was most looking forward to. It definitely lived up to my expectations and
has solidified my plan to pursue a clinical toxicology fellowship following
completion a PGY1 residency. Please bear
with me while I gush about this rotation.
As I mentioned, this rotation
is considered non-traditional as it is geared towards emergency medicine
medical residents (aka licensed physicians who have a few years of practice
under their belts), although there were a handful of pharmacy residents and
medical students on rotation as well. In
total, there were about 25 rotators, so you can imagine that we did not all
physically visit and consult on every toxicology patient that passed through
the Detroit Medical Center. Instead, we
were divided into four teams who were assigned one day a week to be “on-call”,
with the following day designated for team “call backs”. Additionally, each team was assigned one
weekend to be on-call. This was
confusing to me initially because I’m used to traditional rounding which
generally occurs at the same time every day with more or less the same group of
people. Consult services, like
toxicology, are more flexible and can see patients at any time, day or
night. A typical day at the poison
control center looked something like this:
0730-0900 – consults or call backs
On the days my team was
on-call, our designated team leader would call the poison center at 0600 to see
if there were any patients within the Detroit Medical Center network of
hospitals who required a toxicology consultation. Some days there weren’t any patients, other
days there were one or two. It was up to
the team to decide who would see the patient.
I consulted every patient that was available to me to consult, though I
always teamed up with the physicians in my group who performed a physical exam,
asked follow-up questions of the patient and the patient’s nurses to gain a
more complete toxicologic history, and wrote consultation notes for the medical
record.
On call-back days, we were
required to log into the Toxicall system which is the database that tracks all
of the calls that come in through the poison center hotline each day. From here we returned calls to health care
providers who may have consulted the poison center the night before for
recommendations regarding a toxic exposure.
As rotators, it was our job to gather as much pertinent information as
possible about the patient’s history, as well as their treatment course and
most recent labs and vitals. From there
we would consult with the toxicology fellow or attending toxicologists about
what additional recommendations for care needed to be made, and then write a
SOAP note to log our encounter and recommendations in Toxicall.
0900-1100 – case review
Each morning, the on-call and
call back teams would present the cases they had seen. These were case presentations with a twist,
however. Whenever possible, the toxic
substance was withheld so that we could try to guess what it was based on the
patient’s presentation, vital signs, and lab findings. Certain classes of medications have specific
toxidromes that can help clinicians narrow down the possible ingestant(s). For example, sympathomimetics (like bath
salts, amphetamines, and cocaine) cause increased blood pressure, heart rate,
respiratory rate, and temperature, pupil dilation, CNS activation, sweating,
and GI activation like nausea, vomiting, and diarrhea. Conversely, sedative-hypnotics and opioids
cause decreased blood pressure, heart rate, respiratory rate, and CNS
depression. Patients rarely present with
a textbook perfect toxidrome, especially if they ingested more than one
substance (or even if they’re withdrawing from one substance while overdosing
on another). Toxicology requires a lot
of problem-solving and detective work, which made cases my favorite part of the
day. It was just piecing together
puzzles all morning!
Of course, it was frustrating
when the poison was never elucidated because the patient was intubated and
unable to tell us what they took. I was
surprised at how often it didn’t matter what the actual toxic ingestion
was. The toxicologists made treatment
recommendations based on the patient’s symptoms, not necessarily based on what
the patient claimed to have taken.
Here are some examples of the
many and varied toxic ingestions I saw during this rotation: synthetic
cannabinoids, lithium, heroin, glipizide, bupropion, acetaminophen, Coricidin,
Listerine, antifreeze, quetiapine and cocaine, Dust-Off, a caterpillar, and some
chemical called 3FPM that the patient ordered online. We were also consulted about a Massasauga rattlesnake
bite!
1100-1200 – lunch
1200-1400 – lectures, journal club, topic
presentations, field trips
The afternoons were devoted
to lectures on a wide variety of toxicology topics which were given by the
handful of toxicologist attendings who worked at the poison center. We reviewed everything from acid-base
chemistry and acetaminophen toxicity to poisonous mushrooms and venomous
spiders. Each rotator was also required
to present a journal club and a topic presentation. My presentations were on colchicine toxicity
and castor bean/ricin poisoning.
We had two field trips during
the rotation: one to the Detroit Zoo to learn about venomous snakes, and one to
the Michigan State University botanical gardens to learn about poisonous
plants.
castor beans from the botanical gardens |
autumn crocus, the plant from which colchicine is derived, at the botanical gardens |
1400-1600 – review materials, work on projects from
home
My major assignment for the
rotation was to help develop a protocol for the management of zinc/aluminum
phosphide poisoning. Aluminum phosphide
is a rodenticide that’s especially prevalent in agriculture southern Asian
nations like India, but can easily be obtained in the US via the internet. When aluminum phosphide comes in contact with
water, it releases phosphine gas which is super toxic because it disrupts
mitochondrial function. When ingested,
stomach acid causes an even greater release of phosphine gas. Not surprisingly, the mortality rate from
aluminum phosphide ingestion is very high, and unfortunately there isn’t an
antidote. In addition to being
incredibly toxic to the individual who ingested the aluminum phosphide, the
patient can off-gas phosphine even post-mortem which puts the healthcare
providers caring for these patients at risk.
These patients essentially become HAZMAT problems. It’s a pretty fascinating issue. Here’s a link to a news article about a
recent case of aluminum phosphide ingestion in New Mexico: http://www.koat.com/news/man-overdoses-vomit-contaminates-taos-hospital/34890148
And now, dear readers, please
allow me to list the reasons why I love toxicology and thus loved this
rotation:
- Toxicology is a broad specialty because the dose makes the poison, which means that basically anything can be toxic in the right quantities. This means toxicologists have to be well versed in pharmacology and biochemistry, because toxic ingestions can be household items just as easily as they can be medication related.
- Toxicology is all about SOLVING PUZZLES. I love this so much.
- Toxic ingestions often have a social component to them that I find very interesting. For example, lead poisoning is more prevalent in low-income areas because the houses are often older and thus more likely to have been painted with lead paint. Or parents may be reluctant to admit that their child could have accessed their prescription (or not prescription) medications out of fear that Child Protective Services will be contacted. These complicated situations add a whole new layer of challenge to the field.
- I am a biologist at heart, and toxicology caters to this because beyond drugs, toxicologists are concerned with poisonous plants and animals too!
- In my opinion, toxicology offers pharmacist a good balance of activities including clinical care, drug information, research, teaching, and administrative duties.
- Toxicology offers tons of variety because there are always new poisons (see: Tide Pods) and drugs of abuse trends are always changing. There is always something new to learn.
- Finally, I really love emergency medicine docs. All of the toxicologists and EM residents who I worked with this month had the most delightfully dry senses of humor on top of being super smart. It made me excited to come in to rotation every day.
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