Rotation 6: New Patient Resus Bravo

Posted by Emily at Thursday, December 17, 2015

Six rotations down, another Midyear meeting in the books, and Christmas right around the corner!  P4 year sure flies when you're having fun, and I had a great time doing an additional "inpatient" rotation in the adult emergency department at UMHS.

in the ED satellite

This rotation confirmed my interest in emergency medicine pharmacy and as a result, I focused my Midyear Residency Showcase adventure on speaking with programs that have strong EM offerings.  Emergency medicine pharmacists have a variety of responsibilities, and the extent of pharmacy involvement in the ED is hospital dependent.  Some hospitals don't have pharmacists stationed in the ED at all, while others have a well-established pharmacy presence.  At UMHS, ED pharmacists are in charge of verifying orders for patients in the ED, making IVs since there is no designated ED pharmacy technician, managing cardiac arrest and rapid sequence intubation boxes during codes (e.g. predicting what medications the docs are going to ask for before they ask for them, and having the syringe or bag prepped; providing agent and dose recommendations; keeping track of how long a patient will remain sedated and paralyzed based on the sedative and paralytic they were given for intubation, etc.), providing antibiotic recommendations, answering drug information questions, and attending rounds in the emergency critical care center (a sort of mini ICU attached to the ED).  Most of my time was spent in the pharmacy satellite working on projects, topic discussions, and helping with compounding in the IV hood.  But whenever a new patient was brought into the resuscitation bay, a page would go out over the loudspeaker announcing their arrival, and pharmacy would run over to assist.  Not surprisingly, there was no "typical day" in the ER, so here's an overview of how I kept busy during the last six weeks.

What I Saw:

• A variety of overdoses (acetaminophen, alcohol, sertraline, nortriptyline, diphenhydramine, ibuprofen, zolpidem, lorazepam, alprazolam, quetiapine, hydrocodone etc.)
• Several codes/cardiac arrests, which also meant seeing CPR conducted in real life for the first time
• One of the aforementioned cardiac arrest patients being put on extra-corporeal membrane oxygenation (ECMO)
• A handful of motor vehicle accidents (cyclist vs. truck, car vs. tree/telephone pole, car vs. car, etc.)
• Singed nostrils on a patient who had tried to smoke with her nasal cannula still in
• Hypertensive urgency (with a systolic BP of 294)
• Hemorrhagic shock due to GI bleed
• Ischemic strokes
• Dislocated shoulder
• Septic shock
• Severe respiratory distress
• Diabetic ketoacidosis
• A really gnarly leg wound due to a fall in an elderly patient
• Frostbite
• Compound arm fracture

What I Did:

• Helped at codes (twisting together epinephrine syringes, making a bicarb drip, drawing up just-in-case-of-intubation etomidate, handing off meds)
• Verified orders (with supervision)
• Made IVs, including t-PA
• Assessed appropriateness of vancomycin orders and made dose recommendations
• Counseled patients on how to use EpiPens and Combivent inhalers
• Picked up a handful of evening and weekend shifts, and spent some time in the pediatric emergency department in order to get the full ED experience
• Led topic discussions on advanced cardiac life support, rapid sequence intubation, myocardial infarction, urinary tract infection, status epilepticus, appendicitis, diabetic ketoacidosis, burn management, delirium, GI bleed, stroke, sickle cell crisis, phototoxicity, and sexually transmitted infections
• Developed nursing education slides for ED pharmacy bulletin board on details of new Established Status Epilepticus Treatment Trial being conducted at UMHS
• Updated UMHS antidote stocking quota list
• "Precepted" M1 students who were required to shadow a pharmacist as part of their curriculum

ESETT slides for ED pharmacy bulletin board

What I Learned:

• The ED was not as full of blood and guts as I was expecting.  Most of the patients that came in to the resuscitation bays were medicine patients rather than acute trauma patients.  Had I been in a big city like Chicago or Detroit, I would have seen more "penetrative traumas" (e.g. gunshot and stab wounds), but around here we have a lot of elderly patients having heart attacks, strokes, and other accidents - especially during the day shift.
• Heart attack patients can look really asymptomatic.  On TV, people having heart attacks always clutch their chests and collapse.  During this rotation I saw a handful of patients who had been sent to us only because their PCP noticed something off on their EKG; otherwise they looked and felt normal.
• NAC really does smell as awful as we were told it does.

Challenges:

• There are about six different pharmacists who work the day and afternoon shifts in the emergency department, so in addition to my primary preceptor, I would work with two different pharmacists a day and at least five different pharmacists per week during this rotation.  This was tricky just because each pharmacist does things a little bit differently and I had to adapt to make sure I was meeting the expectations of whatever preceptor I happened to be working with at the time.
• The ED at UMHS is a very "feast or famine" environment.  I rarely had a day that was just a steady flow of resus patients.  I would either have days where almost NO new patients came into the resus bays and I would spend all day working on projects and topic discussions, or days when the resus pager was going off every ten minutes.  There never seemed to be a lot of in between, and I would have been grateful for a few more busy days.
• Unfortunately, I also saw a patient die for the first time during this rotation.  

Now I'm looking forward to a couple weeks of break before starting block seven and, even more daunting, residency interviews.  Stay tuned.